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Home My Public Portal About5453 CLOVERLY AVE_Plumbing__ li WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9/89 I hereby affirm that,l have a certificate of consent to self insure, 76A667A APPLICATION FOR PLUMBING PERMIT or a certificate of Worker's Compensation Insurance, or a certified copy thereof(SAc. 3800 Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No. Company ❑ Certified copy is hereby furnished. r_1 ADDRESS APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ADDRESS S -_;t) Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM C FEE LOCALITY f ✓ L 7 4/ t Date Applicant WATER CLOSET NEAREST "7 CROSS ST. l7 (�( � CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK !J PAGE e)rW PARCELv`� permit is for one hundred dollars($100)or less.) OWNER I certify that in the performance of the work for which this permit LAVATORY is issued, I shall not employ any person in any manner so as to SIN MAIL ' _ � �� ADDRESS become subject to the Workers' Compensation Laws. DISWASHER CITY TEL.NO. Date Applicant CLOTHES WASHER 1` NOTICE TO APPLICANT: If, after making this Certificate of JI CONTRACTOR Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER TATE LIC. d (commencing with Section 7000) of Division 3 of the Business and �� SCENSE NO. CLASS O GAS SYSTEM OUTLETS Professions Cade, and my license is in full force and effect. U OUTLETS OVER DISTRICT NO P t= 5 PER SYSTEM O License Number Lic.Class V FINAL DATE VALIDATION W d Sv�� Contractor Date J Ill ❑ I am exempt under Sec. _)r FBY INAL Z B.&P.C.for this reason � Plan check fee Signature Poo. PLUMBING PERMIT ISSUING FEE$ 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 Law for the following reason (Section 7031.5, Business and Professions Address . Co ,): City Tel. No. I, as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). , CONSTRUCTION LENDING AGENCY 1 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 repre�s�0 atives of thi ounty ter upon the above-mentioned ekfor insp n rp '/ SEE REVERSE FOR EXPLANATORY LANGUAGE „Ignature of Permittee Date WORKKER'SCOMPENSATION DECLARATION 20-002APW9/89 APPLIdATION FOR PLUMBING PERMIT I herotry affirm'`that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sar:.3800 Lab. C.) , COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No. Company ❑ Certified copy is hereby furnished. BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) r ADDRESS Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY Date Applicant It, WATER CLOSET ,� �/ Q NEAREST R CERTIFICATE OF EXEMPTION FROM WORKERS' /L BATH TUB, /� PARCEL ASSESSOR COMPENSATION INSURANCE (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE permit is for one hundred dollars($100)or less.) LAVATORY ,ry� O OWNER O`. I certify that in the performance of the work for which this permit MAIL , is issued, I shall not employ any person in any manner so as to ( SINK s ADDRESS C� VuL� become subject to the Workers'Compensation Laws. DISWASHER CITY TEL.NO. Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER 0 (commencing with Section 7000 of Division 3 of the Business and STATE LIC. ( g ) LICENSE NO. CLASS Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS V OUTLETS OVER DISTRICT NO. PROCESSED BY 5 PER SYSTEM �O License Number Lic.Class _ FINAL VALIDATION DATE Contractor Date CO ❑ FINAfL Z I am exempt under Sec. BY BAP.C.for this reason Plan check fee } Date: ANT.g. PLUMBING PERMIT ISSUING FE$ Signature 74'g 3307 114..1` TOTAL FSE El Plan check applicant 1 ITEMS SINGLE FAMILY TOTAL :114 15 HOME OWNER-BUILDER DECLARATION Name 1 hereby affirm that I am exempt from the Contractor's License Law ,. j 114.1c for the following reason (Section 7031.5, Business and Professions Address CASH Code): CHANGE .100 ❑ City Tel.No. _ _ - 1,as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). f;, 0000-000100-0001 9/10/921 CONSTRUCTION LENDING AGENCY 5415 1 AM :1a 1 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 co ect. I agree to comply with all County ordinances and State la Lfrelating Plumbing, and hereby authorize representativ s oty to enter upon the above-mentioned property fo inspses. _ — L SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ature f Permittee Date