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Home My Public Portal About5828 BURTON AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 7A - -- I hereby, affirm that have a certificate of consent to self in- 6i566 DPW d/90 bE7A sure, oro certificate of Workers'Compensation Insurance,ora certified copy thereof (Sec. 3800, Lab. C.). - - Policy N911 Company - COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ❑ Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) F�- Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Dote ' Applicant WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work Involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK CITY TEL- NO. mit is issued, I shall not employ any person in any manner so ' as to become subject to the Workers Compensation Laws. - DISHWASHER CONTRACTOR Date Applicant j CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subjeU to the Workers'Compen- CITY TEL. NO, sation provisions of the Labor Code,you must forthwith comp- ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. - WATER HEATER LICENSE NO. - CLASS LICENSED'CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS y 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER a and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION O feci. HOSE BIB DATE U License Number Lic. Class - UJI FINAL LL Contractor Date BY - y El ac I am exempt under Sec. 8.&P.C. for this reason 0 ti' O Plan check fee ► - ?:. a t fid ,40 Lin � Date:- PLUMBING PERMIT ISSUING FEE$ d" w H Signature TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and Professions Code): Address I, as owner of the property, will do the work and the City Tel. No. structure is not intended or offered for sale(Section 7044, Business and Professions Code). , CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address 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 representatives of this County to enter upon the above-mervioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS' COMPENSATION DECLARATION APPLICATION FOR. FLUAIi03ING PERMIT' hereby, affirm That have acerhfi tate of'cbnsent to self In 20-0026 DPW 4/8➢' sur%or o ceriificaie of Workers'Com ensation Insurance,ora 76A667A 1 P CE 817(REV 8/86) - certitietl copy thereof (Sect 3800 Lob C.). ' ~f '• - COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS - PolicyNo. Company - + - Cernfiisd copy is hereby_firnished _ P �, FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING r . 'Certified copy Is filed with the county building inspection : - ADDRESS ,/{f n ` - NUMBER FIXTURE OR ITEM ' FEE _ - ,q e .. LOCALITY X WATER CLOSET(TOILET) �"50' Date�• �Applicant - _ NEARESTj. . - CERTIFICATE OF EXEMPTION FROM`WORKERS' BATH TUB _ CROSS$i • ,�, ,�, /V�S. ).4 ' COMPENSATION MSURANCE - ". SHOWER OWNER 't, y� (This�sectton need.not be completed if thelwork mvolved.by. the_permit is for one hundred dollcrs"($100).or less'.) LAVATORY' - ADDRESS certify that In the perfoimance'of the work for whi chtF ispei SINK m Itis Issued„I sholl'not employ any persdn'in any manner so - CITY 'TEC NO.- r as to become subject to I e,Workers;Compe al on'Laws. DISHWASHER _ - ' CONTRACTOR. DateAppli cant - rT ' CLOTHES WASHER - ADDRESS ` NOT E TO•APPLICANT If, after making this orker cate'open- � P � - - SWIMMING POOI RECEPTOR + emption, yovshould 6ecome'sU6l e'cblo theWorkers'Campen sation prov15mns`of the Labor Code you must forthwith comp �qV•/N SPRINKLER SYSTEM ly with such provisions or this+permit sholl,be deemed•revok - - STATE r LIC 1 d - - WATER HEATERLICENSE NO. ^ ASS LICENSED,CONTRACTORS DECLARATION. DISTRICT NO. R CESSED y ' hereby affirm,that I am licensed under,prov,slans of Chapter GA$i$YSTEM ;OUTLETS 91(commencmg with Section 7000)of Division 3 of the Business - OUTLETS OVER ' - ondlProfesslons Code, and my license Is,in full farce and of 5'.PER'SYSTEM FINAL �^1 '/ - V LIBATION 'y fectf'.r . . DATE. License Number LIC. Class - - ._ Contractor - -Date - - BY - •f O .I.am exempt und6,Sec. W. •,B for this reason - - .Plan check fee' - CL 8P C D Z ;Date: 11.PLUMBING PERMIT ISSUING,FEE$ - Signature TOTAL FEE - + - - o .. ' SINGLE FAMILY iq Plan check c lic - - HOMEOWNER-BUILDER DECLARATION PPaFit- „ hereby afflrmt{iat I am'ezempt tram the Contractor's License .Name',- a Law for the following reason'.(SecL on 703 A:5 •Business and PCI rofesslo 5 Code): :. Address S. O 0 �3J�7": as owner.of the.property, will do:the work and^the City ��' Tel. No. �� p! 1 .IT ITructure Is not Intended or affe)ed for (Section 7044 �.Ss 6-30 , TOTAL ITAL 43 - 00- mess and Professions-Code / CONSTRUCTION LENDING AGENCY .- ''f - - . " ` - - CHECK, ' 43.01 hereby affiim;thdt there is a construction lending agency for , .r ' ” 1 CHI thexperformance of the work for'v)hichthis permit is issued. (Sec.;3097 Civ. C.).: Lenders Name . . _ UCECrj :i_--OfJ 1 6/ 4f9' 1.4 Lenders Address ' ” I,certify that I have read this application and state that the - acove"".Information is correct. ]agree to comply with all County - - „ordinances andState Iaws:regulating Plumbing, -no.hereby authorize'represenrotives'df-this County to enter upon'the npurposes. - '- abave;meIo ed`.property for action purposes 1 ti C� -�(� YSEE.REVERSE FOR EXPLANATORY.LANGUAGE Ignature•of Permittee Date . ! I� PLUMBING �p II II PERMIT I� y WORKERS' I have 6 certOfV ie-of consent APPLICATION FOR Ir IL YJtMBING Ir l�ll`(p I . TION I hereby, affirm that I have d certificate bf-consent to self in- 76A��gDPW'4/9D LVE II CI 9HC sure,or a certificate of Workers'Compensation Insurance,or a certified cap the o} (S , Lab. ��// ,r�/ t Policy N . �, ompanyL=n` L( CCC I// ��/ COUNTY OF 105 ANGELES DEPT. OF'PUBLIC WORKS C reified copy is hereby furnished. J 1_ FOR APPLICANT TO FILL IN PRINT OR TYPE BUILDING Certified copy is filed with the county building' n ( ) ADDRESS NUMBER .FIXTURE OR ITEM "@ FEE LOCALITY Date a !�' ' t • 4Cpplimnt WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM.W RS' Z.' BATHTUB. - - CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This sectionneed not be completed'if the work,involved.by .MAIL the permit is for one hundred dollars($100)or less.) 4Z, LAVATORY'. ADDRESS;.) U - IS-ZI' 7e/LI I certify that in the performance of the work for which this per- - SINK mit is issued, I shall not employ any person in any manner so - CITY �' r TEL. NO, as to become subject to the Workers' Compensation Laws.. DISHWASHER CONTRACTOR Date - Applicant / CLOTHES WASHER - - ADDRE NOTICE TO APPLICANT: If, after makin is Certificate of Ex- ! - SWIMMING POOL RECEPTOR emption,you should become su bj o the Workers'Compen- CITY A iJ G ��10. C' j sation provisions of the Labor e, you must forthwith comp- - LAWN SPRINKLER SYSTEMS ly with such provisions or s permit shall.be deemed revok- STATE - tt �j /` LIC.— ad. WATER HEATER LICENSE NO.`v �'�`—(�J� CLASS LICENS CONTRACTORS DECLARATION DISTRICTMO. - PROCESSED BY I hereby affirm at I am licensed under provisions of Chapter GAS SYSTEM OUTLETS Q� 9(commencing with Section 7000)of Division 3 of the Business - OUTLETS OVER and Professions Code, and my license is infull force a e - 5 PER SYSTEM FINAL VALIDATION tett. /� 7 HOSE BIB DATE License Number `,,1/ l:c-/ i Llc Class �� '� a FI 0 A4GT Contractor //✓/ �.� te !/' r .4 () 3303 301.00 F-] 6' am exempt under Sec. .. 1 ITEMS 0 B.BP.C.for this reason Plan check fee (�[}7(Q L,0013 a PLUMBING PERMIT ISSUING FEE,$- O �y v"""" 3O " "'" Z Signature ' TOTAL FEE 71 �, O 0 CHANGE' .00 ' S1 LE FAMILY - - HOME OWNER-BUILDER DECLARATION Plan check applicant ' I hereby affirm that I am exempt from the Contractor's License Nome X00-0001 'E/22/95 Law for the following reason (Section 7031.5, Business and Professions Code): Address 1931 1 AM 8:04 I, as owner of the property, will do the work and the City Tel. No. structure is not intended or.offered for sale(Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY, .D I hereby affirm that there is a construction lending agency for - r the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Nome - Lender's Address - - 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 representatiis County to enter upon the above-mentioned`.pro rtyJa inspection Pur ores. ` � 4�� SEE REVERSE FOR EXPLANATORY LANGUAGE SignotCre4Sf Perritt -Dote