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Home My Public Portal About8752 BURGHARDT RD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT reby affirm that I have a certifnaoe f consent to self 76A667A n re, or a certificate of Workers' Compensation Insurance, CE 017(REV. 10/81) r a certified copy thereof (Sec. 3800, ab. C. COUNTY OF LOS ANGELES IJUILDING AND SAFETY Polic Compan l .4//tli✓� . Certified copy is hereby furnished. ❑ FOR APPLICANT i0 FILL IN(PRINT OR TYPE) BUILDING ^� C/ 6 !/� Certified copy is filed with the county building inspec- ADDRESS / // tion department. NUMBER FIXTURE OR ITEM ® FEE s '� LOCALITY q ,C C,C- WATER CLOSET _ Date�L App li4a �` NEAREST ST. / Q� CERTIFICATE OF EXEMPTION FROM WORKERS' L BATH TUBlta� COMPENSATION INSURANCE / OWNER J SHOWER W C' (This section need not be completed if the work involved by C the permit is for one hundred dollars e wow or lesshi 6- LAVATORY ADDRESS/0,0"'J/67 7�.7 I certify that in the performance of the work for which this / ` P p y y p y SINK 6 CITY TEL.NO.yl�sZ permit is issued, I shall not employ an person in an manner �y a so as to become subject la the Worker C ensa'on Laws. / DISHWASHER !�3B CONTRACTOR Date Applicant// "'�' 'VLA CLOTHES WASHER NO ICE TO APPLICANT: If, after making this Certificate of ADDRESSG- Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY TEL. NO. LAWN SPRINKLER SYSTEM 10� with comply with such provisions or this permit shall be STATE rr LIC. deemed revoked. / WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO PR .BY I hereby affirm That I am licensed under provisions of Chapter 9 ` GAS SYSTEM OUTLETS to 6 (commencing with Section 70D0) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL a DATE ALIDATION V License Nu mbe Lic. Class � �� ps 'y F� AL / O Contrac BY Date F-�-�.�••• ~ V ❑ I am exempt under Sec. t L !7 [/ CL w B.BP.C. for this reason N Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ `D Signature J TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name ` I hereby affirm That I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the structure is intended or offered for sale (Section pop �-- 7044, Businessss and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for c c c c the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). - 1 C;a rJ(, Lender's Nome - ' ) 06 r G i-'' Lender's Address (' -F j I certify that I have read this application and state that the ► above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize represeman ,s of this County to enter upon the abov enti n ro erty f inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION APPLICATION FOR PLUMBING PERMIT hereby, affirm that hhove a certificate of consent to self in- 76A667 DPW 4/87 bA66]A sure,ora certificate a4 Workers'Compensation Insurance,ora CE 817(REV. 8/86) certified copy thereof (Sec. 3800, Lab. C) Policy No. Company I COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Certified copy is hereby furnished. y� FOR APPLICANT i0 FILL IN (PRINT OR TYPE) BUILDING III � w'1l SA4 (1- 21E Certified copy is filed with the county building inspection ADDRESS - department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET(TOILET) NEAREST i'G n �L�� °� '- I CERTIFICATE OF EXEMPTION FROM WORKERS' - BATH TUB CROSS Si. LIS�7'1�Lrr& /LD1K360 1�/ COMPENSATION INSURANCE SHOWER OWNER rCR TisL--+�1L (This section need not ba completed if the work.involved by MAIL p ^ ESI, ` �r�r�r� p� the permit is for one hundred dollars (5100)or less.) LAVATORY ADDRESS 81Sa z5L1;Z6V7' P–D •'-- I certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in SINK any manner so CITY SAM TEL NO. .Z as to become subject to the Workers'Coni ti n ws. DISHWASHER CONTRACTOR Date ApplicantCLOTHES WASHER ADDRESS NOTICE T APPLI AN : If, after m ng this Certi icate of11� SWIMMING POOL RECEPTOR emption,you should become subject to the Workers Compen- CITY TEL. NO. sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER /'f LICENSE NO. CLASS LICENSED CONT eased under CONTRACTORS-DECLARATION c� DISTRICT NO. P OCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �— D / 9(commencingL with Section 7000)of Division 3 of the Business OUTLETS OVER o d Professions Code, and my license is In full force and ef- 5 PER SYSTEM FINAL,-7f VALIDATION fe4 DATEj O License Number Lic. Class U FINAL 2 Contractor Date BY O F OI am exempt under Sec. I W a B.SP.C. for this reason Plan check fee i Date: PLUMBING PERMIT ISSUING FEE $ Signature TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant r-• I hereby affirm that I am exempt from the Contractor's License Name 13 FEE Law for the following reason (Section 7031.5, Business and Professions Code): Address �1}[il]–i!I}!j 2/10/8?' I, as owner of the property, will do the work and the City Tel. Na. _ structure is not intended or offered for sale(Section 7044, 11701 1 Ali =2? Business and Professions Code). - orCONSTRUCTION LENDING AGENCY, 1 hereby affirm that there is a construction lending agency for ACCT'r the performance of the work for which this permit is issued aoU7 122.50 (Sec. 3097, Civ. C.). Lender's Name TOTAL d ? o mo= Lender's AddressM--, c CCHECKt[. I certify that I have read this application and state that the above information is correct..I agree to comply with all County ` CHANf7c ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the *above �aned rty forinspe on purpos s _./p ,QSEEREVERSE FOR EXPLANATORY LANGUAGE erm' ee Date 717 j 1 AM �?e;�O