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HomeMy Public PortalAbout5806 & 5808 CLOVERLY AVE_Plumbing__ t KERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT that I have a certificate of consent to self 76A667A�A�y,-Jt, certificate of Workers Compensation Insurance, CE 817(REV 10/81) or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY 'Policy N mpany CNA © Certified copy is hereby furnished o y5 _ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING, \ fU•U' Certified copy is filed with the county building mspec- ADDRESS `L 868 biio Y A - NUMBER FIXTURE OR ITEM @ FEE tion department LOCALITY TMPTyl TTTY - Date 12-1-88 Applicant OWNN PLUMBING CO 6 WATER CLOSET 36 00 NEAREST 1 CERTIFICATE OF EXEMPTION FROM WORKERS 6 BATHTUB 36 00 CROSS ST COMPENSATION INSURANCE SHOWER OWNER TRI TECH DEVELOPMENT m (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less ) 6 LAVATORY 36 00 ADDRESS W. EMERSON AVE. ^ I certify that in the performance of the work for which this - permit is issued I shall not employ any person in any manner 12 MI SINK CITY MONT P TEL _0204 so as to become subject to the Workers Compensation Laws 2 DISHWASHER 2 00 CONTRACTOR Date - - - Applicant - _ - -_2 -� CLOTHES WASHER _ _12 0004EN Y NOTICE'TO APPLICANT If after making this Certificate of ADDRESS`2019 'SAkTA ANITA—AVEj — - +-�-t -- � Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR" Compensation provisions of the Labor Code you must forth- CITY S. MONTE CA., TEL g�g,(+4/Z_37Qj� LAWN SPRINKLER SYSTEM J`+ with comply with such provisions or this permit shall be STATE LIC deemed revoked WATER HEATER r 12 00 LICENSE NO LF CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 2 GAS SYSTEM OUTLETS ti / + (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and effect 5 PER SYSTEM FINAL + x+51933 C-36 4 o DRA S DATE 12 VA ION �� License Number Lrc Class Qt OWEN PLUMBING 12-1-88 FINAL • O Contractor Date ❑ I am exempt under Sec N B &P C for this reason ;E_ Plan check fee Date � - PLUMBING PERMIT ISSUING FEE$ 10 50 Signature r TOTAL FEE 202150 2 1'2-a 5,A, Plan check applicant # o o e o 05 SINGLE FAMILY I -'20250 HOME OWNER-BUILDER'DECLAR ATION Name I hereby affirm that I am exempt from the Contractor's License 0 2" x. Law for the following reason (Section 7031 5 Business and Address I o,2 �,�2 C Professions Code) - City Tel No ❑ I as owner of the property, will do the work and the A structure is not intended or offered for sale (Section , v 7044 Business and Professions Code) ' CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for y the performance of the work for which this permit is issued (Sec 3097 Cry C ) e 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 1 authorize representatives of this County to enter upon the above-mentioned pr erty for inspection purposes ' SEE REVERSE FOR EXPLANATORY LANGUAGE LL Si ture of Permittee Date r° � ' RKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERiU11T, {� rm that I have a certificate of consent to self 76A667A u sure di a certificate of Workers Compensation Insurance CE 817(REV 10/81) oro certified copy therepof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING,AND SAFETY Policy No.GII(1400528505 ,any CNA 7 IN �'+ 4 ❑' Certified copy is hereby furnished 4 y FOR APPLICANT TO FILL INPRINT OR TYPE BUILDING w p,�' � - 'Certified copy is filed with the'county building mspec IN( ) ADDRESS 50118 CLO Y AVE-, V tion department INUMBER FIXTURE OR ITEM @ FEE LOCALITY l ~~ }4 Date 12-'1—gg Applicant OWEN 7iMmis. m. WATER CLOSET W NEAREST TEMPLE CITY CERTIFICATE OF EXEMPTION FROM WORKERS 6 BATH TUB 3q 00 CROSS ST COMPENSATION INSURANCE SHOWER OWNER TRI'TECH, DEVEWEMENT (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less ) 6 LAVATORY 36 00 ADDRESS 735 W- EMERSON AVE. I certify that in the performance of the work for which this 2891- 02011 permit is issued I shall not employ any person in any manner 2 SINK 2 CITY MONTEREY PARK CA. T118")443-3384 so as to become subject to the Workers Compensation Laws DISHWASHER 2 12 OO CONTRACTOR OWEN pIUMBING CO- _—Date Applicant _ �^_,- 2 CLOTHES WASHER _ _1 _00 ADDRESS-20-19— AVE----L-- NOTICE _ TO APPLICANT If after making this Certificate of Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR CITY S. EL MONTEi CA. TEZO)443-3384 Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC deemed revoked WATER HEATER 12 00 LICENSE NO 45"1933 CLASS /C-36 LICENSED CONTRACTORS DECLARATION DISTRICT NOPR ESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 2 GAS SYSTEM OUTLETS '1 00 c� (commencing with Section 7000) of Diwsron 3 of the Business OUTLETS OVER / and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL ALIDATION 451933C-36 4 ROOF DRAINS 2 00 DATE License Number Lic Class O OWEN PUUMBING 12-1-88 U Contractor Date ❑ I am exempt under Sec ' b I 'j O 120250 U B&P C for this reason W Plan check fee a Date (f) PLUMBING PERMIT ISSUING FEE$ 1 50 0,020250=0 Z Signature TOTAL FEE SINGLE FAMILY - Plan check applicant 120,1 -88 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 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 ) o e , Lender s Name a 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 me bone �Iorn purposes ` SEE REVERSE FOR EXPLANATORY LANGUAGE SiqyQure of Permittee Date T.� �Bw^ ~' aF r_ ` W''r _< , �, cr ~�' } '7 A .,. .y +.. >tik `✓w �; u`l fv ti{ j ,.^4.1t ...� ki., w t +' ,� , . , > .�'!J"� el b' 4 r' WORKERS' COMPENSATION DECLARATIONti, + t gam. 5 �a200026DPW4787�t�=q-"APPLI'CAT.ION FOR PLUNIBIIVG bPERIVII;T '� I hetieLiy affirm thatrl hale a,certificate-of consent to.self�n ,76A667A r ,s " *r a°. +` ^ + -'suie or,a ceriificate of WorkersyCcmpenscition'Insurance ora -'CE 817,(REV e8/86) f _ f� _ ,*_ ^, y^ + re s s r +.�. e � �'� °,�. ✓: s', ce tified copy thereof (Sec^ 3800'Lab C a•� t yp,�yy�, COUNTY-'OF,LOS. °r - ;° , ate DEPT OF PUBLIC WORKS - y Po Ie h O� Com Ofl P Y t- q.*,'° 4 s,rr +.. ,to +eis4+y y.3• L �r�.� � _, ..,, Ya - ` - '� ,qx ' ° si ,rp'7 �'+ ,^r `+f �` �, �`'�, ,.,J��.�".fir+ '�r ;<�,.. - i � ' ,� '�'��:,a�_ r� �v ++�r� �"� a `.� . .3" � ,�,,•. .� r` `�'.+, i ...�r tertifiedtco is'hereb furnished o t .t� c 5 r p ,_„+l -o BUILDING r ».r R 'r q,' t rglp n n -coFOR«APPLItCANT+TO FILL IN,(PRINT,OR TYPE) : x s` ;�Gert.fied,copyas+filed with the unty building inspection _ e „- ADDRESS (i, NUMBER k FIXTURE OR ITEM FEE' @� x. 1_ ," w v y i 'a x ' ��`j„'er: k > � T _ _ ,� ° 'LOCALITY �e7we, ti 3' '� �' ar k 5f"w t r ; 1 `' 1 =a� ��,F `r S T a w < �' ✓^' a .�` ,aFd' (/1 y '�"G tri .....^c.^,. r f�Y.:d tt rk r if �N Ds � E �(,�,� rl WATER CLOSET`(TOILET) "+' y� ! y n a't �- �a Date« 1 s' A Ilcan`t;'+ b e. n„ tai ,ate, h T t- r � s pp NEAREST' .e * °t r , `' .'_ �' �,...v ISE_ > 0K L,- 3' " "t e# ,,CERTIFICATE OF,eEXEMPTION FROM WORKERS '* r 'BATH TUB �+}� ? �� o z+ aN bL, COMPENSATION=INSURANCE �r -ar OWNER> �, ""•'a'.<t r f mow- w s +SHOWER ? k°< s, c<� d'cr, .� z 0°J(THiAecfi n,need not be completed rf the,work'involved by ` rva` : w z s - _ ,o�, <-�my '�- a4. :V^' *ice "v� ark MAIL s` j"the permit rs forrone,hundredAollars ($,100)'�or less`) ,"°Y 61 "^ «^ +LAVATORY *-"- 'w,, ' `"t "a- ADDRESSS "�o S,�s' 4i4 -- o^' rv°, �_ I 'r b n . ,.. ' _ I certify that in the performance of-the�work for whichlfhis,per- ry r- �s' a , `s d d 7 + ,. p ` xSINK<� �j `a �,yt, r � CITY f; /T(/ ri!, t{✓I'�!3 4' a...°TEL N0�3�<",. �mlt is"Issued I';shall'not'employ,any-'perso-n'In,any,manner,so` 'o-�. :e<✓ � " i r,' f F ^' asg-1 be come�isublect to th'e�Workers Coinpen`sallon Laws`�Jx' '' °` ^,t �^i �' "' "��` � r� �� � r ^ a'f �t� DISHWASHERt, vJr r s' �}� s;, ? r`� e M# `CONTRACTOR w Date tli e W �PPIICant r +K 43 _ .4- 'p, a w,`� s rt_ CLOTHES{WASHER., y �. �J t i s4+ tib " -a�'��4 `-...t ,A� oaf-- -� ��m y_ ADDRESS ` NOTICE TC APPLICANT If+,afte�grrSakin this Certificate of Ex " d » '� r "s+ - i s r. nr+ r 9 w Se 4 aA a• SWIMMING POOL+RECEPTOR / '� F *`� wb 5 A a emptron*you should become;suv lect to thetWorker`s'Comperi" - t �- F +„ ,.<, , TEL'NO" sation ro visions�of the Labor Code ou�must,forthwith,co'm a+fi a c; P s m . y r "v, P °�„rY' < A .LAWNSPRINKLERpSYSTEM X lyrvvith such p'rovision`s or thisf? ermit'sholl;,be deemed revok'+ K - - T �' STATE v �` LIC- ;d IC "icy �4 ed, 4`*s w `'° fir ', e t �� s,t e d sWATER'HEATER`,- Z �`, }'� ° -, ' LICENSENO -v,'f�ti ,�'�'9b CLASS as'ra -3"" �>+ r- � _ ..++ ,.�_ "� 4 r ,., "i t K; LICENSED,CONTRACTORS DECLARATION ��"e s STRICT�NO" + ,° OCESSED�BY - "; ;kL 'r`.i` � r a`4 , \ GAS SYSTEMA Ate,�=1 > ,c ; ,r OUTLETS' I hereby offlrm'thotfl am hcensea4under,prsov srons;of CI apter,4 ' ''E k = K SFr 9 commenun with'Section 7000 ofiDivision 3,of the Business t OUTLETS OVER ''�" v �* MW o z Y '(� s .'e^gti r a )y d ^+ ';'� r'ar 5 PER SYSTEM.•'7� � �S 4`t� d -}.• , t r �"... andrProfessions Code"and my license�is'in-full,force,,pnd eft FINALS rt ALIDATION� F.f t feC1 �.; y I I% , Kx' �,o r ?� I r` $� i.� , _ -DATE l,5h5 '",�,'� >i �a 6 n. V1Te V,.� •,�• ' >LicensetNuinlier- LIc�Clasqyy 'V ,..�,. "�� FINAL' i'� ✓�� +K���� �Ea � y 1g�� 4 �iP�" s.,= f c o n fircc Coniractorl., ,'�''a`s.:ve"+^'> ``.' + i'S<Iy✓'+yam. ra. < i r'ar gyp. �'•k- jR.� �' _ rr ;,a < , x e _ , �i.. , .+y {�' F7a Pain exerrm t undear Sec'= d� rr .� �' <,{,,„w v° ; ,L - '1 ;•* T ,�',`s , v-}n�.'�< �,r� 4 'a4A 4 �'i" B_&PC f' his ieason +� Plan ch54 �i meq" r �, � eck fee�, �T Date PLUMBING'PERMIT<ISSIJING FEE $, > " 5��'` r ? �, ' �a ' q7 'PLUMB wr -� rb ' h n' <m i�.� s, 27 < W 47Ye t -4- S dture ..4..., s,Signafure =�,-qbr rr �' .Y-, ,;a-a , �} ' q, `�r"y :'F<T'" , TOTAL FEE"'° ,.,•:rte :�. �✓,-� Tn,o�sr tt`7fy ' �.;',^ w '-z .•ere "-4 .. '4. ,', �� , ,h a"� t - x', L `7 d'< 'L , ° ' "'�,>, ` F h �,is ✓`� 'SINGLE FAMILY, '°S'<"�, recSx tom, i x, & �zp xa.- HOME OWNER-BUILDER�DECLARATION�t '� t Plan check«applicont„t� s� D °'._ „Sv_d ,.�' `}+:<: I herefi saffiim that I a-0$'xein t+from the Contractor s,Licen�se'� " ° � � r - " �' J f " ► + ��o a ° +e. �� P Y P_. Name a . , � t. s. 4a, 4 "fit ; rte , . r�, , La�v�for the following reason,(Sectwn�7031 5`Busine"ss`rarid,r '� e'_�; '' + ^4 `° ��`' =r „� b' 4" �'' > ' ' rf�i � 't Yra y-, we✓P ����rl LTo4 r-A Professrions,Code)aia �tf�"+ }s'' Ns res Adds *�3,;t .'j " 3 7a r� •b'A- + o�,Ak,S� r`at .. Y 't, s�. `M1��i-, -7 T r,.�r ( I `s„a e v F1 `I�tias_owner of the ro ert will do the"work+and`they City- No' �P P Y < ..�Y+ j 4a 4T['�t-+" ' q �T n a s a 1'r' J rA +I ITEMS �.+structurekiis not'intencled orloffered,fo�sale(Section 7044 a - q, '; ` �. t,.•, �!�rSj. e i e L'a e"fie r' r" Rs 1 ^'a,,�_- 'gJ sBusinessdndProfessionsCode � ,. . - r , ,,� t-Y�`e•*` >' „c4 �'b' , `� i' +`r °+ -.fv r � -� ,�� )f '"� t.`" , w+ .. a E3R. ` 3'9i k" g R ♦ `4 d TOTAL, -g ' ,#. yls�` "ra ( � r', t � „ <S"";',✓ -, + , a < 5" fi.� �®�' �.' z.,< � Il+��� � ``�-.$.6 m ... 9...T ���,�,� a ., t p h sT 3q �t' ?� + .k•a 4, rw $'� r ,'( S& " s9 ^, i y '' e,CONSTRUCTION LENDING AGENCY a ; + wyF, r tri �� ., • �_ t ti.� +rn� ,s" '� w� � + L {/ �, � T r A- 1'`�y.` Y"r <ri - ° i;r�l,,Sy °ms`s « •.` _ s',. •Yt a IIC.�i',e n, s,Sia "l.ra „I hereby affirm that there•is`a'construct�ion-lendirig�agency for �v �� Y" a *w t , �, a' i ',> ',r a° ` ,H �p''y }` "q. pe o r� fid" F. i[. a t t l •,,e+ ,the performance of"the work`for which this permit is4issued '1*•-�,�4'^r ,' ";,>r s ' s [`} t3�� �» z' ,�.L'Lt4:� tJ -,1' ',_ `b. ty. ir) , .'�•�.' y .+ r z " +' + y „,,�,. ✓ a.. `r%,,. ^' +. 'v ', t (Sec ,3001 Civ.C1) �,� s �, rc 4 a 1 y ro,-r'.2.P �$'r r 'a� a; r1.. i , f:r- � �� J✓a.�r .N' 'Sn }A n `t "xw,. r tw. .C}' ` �'E 'ky �T ': e t r`' k✓- {t ,-rte 4..} ✓ `, 4'yt ''b°�y a "r � r w ,r ;r f^' i,r_ _''h '�`�i"., '�'rT =�,' �`- .,.3'e f�s Kti,+t" �+..+,,• ��.t �T1s la R + .y r '.e 19 ti ,s..t a�"_ 'i',�_.re,^� `+��. A�C., . f y 7I , �k�e ��,,- .a, �, ,���"� '+ a„ 'r w,1 •�� <z'$, �� �'��"�7 '- + { T Lender s,Name �Lrlr.1"_��LE �! a ^_ "y t1,,. e e' +s D"� x�• y ° "i 'L :m *., rR " ���><.ne.. r,,..1 a , vbue e� ry-+ ' 'Le_nder,s,Addryess 7-)7-1:_ ." 4 ;,sw ^" Q h"' •.'W.t 7 a �' n- µ '�y�' „i�`-a-' _ s4 +,'3 � -R ° «> >^�` '` ' wp ,;'1✓ +�Hi 7' °l�_.`�a. _ 'P ,° e IP r , +RJ :F° g ,,`tae �a r,z< �"'4t ( certify that,llli6ve read this appllcation'a_nd state that the aboveinformation Is correct I'o gree to com I with`all Count 'r-, v nn-g + P Y; Y rti" o" ,.S uT z , y t' e� .2 a - r®o f `d' w Y .✓. �' 64 r# n e, "=ordina'nces and Statewlaws regul6i Plumbing ,ond`heseby5 '' author iefarepresentative`s'+of,this County tooenter upon the o alio"ve-me bonedy,property,for inspection purposes V tib � ' r' )e� ' '�r�SEE REVERSE�FOR'EXPLANATORY1ANGUAGE" '" "y �� " a^ �G`•�'d +` ' f Y` �' r r?� •y+ ` SIg_ "cure"of Permittee' Date" +' 4' ' 1 . "�� g4 s�+ , ., �- "'f `' .,�� " i _ C, s+v'k ��`�".' ��..7 i.� w-0'. � ��. � ^ ' �. `� .f�. .9 i '�' ` •`�`y^'u .a. ° e s t�,n �� -..< •+" I ° � r"e, r _. +a .. �, � . _ . � _ -�