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HomeMy Public PortalAbout5830 CLOVERLY AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby, affirm that I have a certificate of consent to self in- 76A6667A PW 4/90 sure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN (PRINT OR TYPE) Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date 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 ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK CITY TEL. NO. mit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws, DISHWASHER CONTRACTOR - Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- I CITY TEL. NO. sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER } d and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION U fect. HOSE BIB DATE License Number Lic. Class W J FINAL ILL. Contractor Date BY } Q 1 am exempt under Sec. cc B.&P.C. for this reason Plan check fee O ► a Date: PLUMBING PERMIT ISSUING FEE$ 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 offirm 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-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 76A667A 1 hereify -affirm that I have a certificate of consent to self CE 617 (z-so) APPLICATION FOR PLUMBING PERMIT insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) Company Aetna Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING DRESS 5830 Cloverly Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE pie artm Y. - LOCALITY T6Tle City Date11/h� Applicant Owan 'Bros,-Phohimg WATER CLOSET r NEAREST c.�./ BATH TUB � CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE 3. SHOWER OWNER Chris Construction LAVATORY MAI L (This section need not be completed if the work involved ADDRESS 2416 Florence y by the permit is for one hundred dollars ($100) or less.) SINK - 112 CITY - - TEL.NO. _ CL Arradia18 0 I certify that in the performance of the work for which thisDISHWASHER �7� U permit is issued, I shall not employ any person in any manner CONTRACTOROWen BroS.Plumbin so as to become subject to the Workers' Compensation Laws. le `l - 0 CLOTHES WASHER �V ADDRESS0 Date Applicant 4265 N. Baldwin Ave. 1— SWIMMING POOL RECEPTOR U NOTICE TO APPLICANT: If, after making this Certificate of CITY El Monte TEL.NO.[ 3-0078 W Exemption, I LAWN SPRINKLER SYSTEM p you should become subject to the Workers' STATE -7 LIC. Compensation provisions of the Labor Code, you must forth- ^ LICENSE NO. 231 /41 CLASS C36-20 with comply with such provisions or this permit shall be WATER HEATER if deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PROCESSED BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER �© I hereby affirm that I am licensed under provisions of Chapter 15 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATION ness and Professions Code, and my license is in full force and DATE — 3 �� r effect. License Number 231 741 Lic.Class C36p-20 BY AL Contrac@weri Bros�P�PI.Date 17�6/pQ f�/��/� `�•=-d¢,�,r ElI am exempt from the licensing requirements as I am a Plan check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE Lie.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's Address License Law for the following reason (Section.7031.5, Busi- City Tel.No. 9 3 0 5 5 A ness and Professions Code): I, as owner of the property, am exclusively contracting # 0 0 0 0 0 5 with licensed contractors to construct the project 2;0 1 1 8 0 0 (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY ° ° 1 1 00CJ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 1 1, 13-80 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 SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby au^rize representatives of this County to enter upon the a ove a io ed property f r inspection purposes. 11/6/80 Sig re of Permittee Date