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Home My Public Portal About6019 CLOVERLY AVE_Plumbing__ WORKERS'COMPENSATIONDECLARATION CE 8176A667A APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self ce e» (z-eo) insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof Sec 3800,Lab C) COUNTY OF LOS ANGELES 7— ' BUILDING AND SAFETY _ Policy o Company D Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ADDRESS Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE i partm�nt �/ / _ /J LOCALITY Date /Applicant WATER WATER CLOSET NEAREST < / BATH TUB CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER , hiV1 (This section need not be completed if the work involved LAVATORY MAILADDRESS by the permit is for one hundred dollars ($100) or less) SINKO TEL NO O U I certify that in the performance of the work for which this DISHWASHER permit is issued, I shall not employ any person in any manner CONTRACTO O so as to become subject to the Workers' Compensation Laws CLOTHES WASHER ADDRESS` /r U Date Applicant W SWIMMING POOL RECEPTOR CL NOTICE TO APPLICANT If, after making this Certificate of CIT ��. TEL NO Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE l LIC / Z Compensation provisions of the Labor Code, you must forth LICENSE NO p� CLASS {X with comply with such provisions or this permit'shall be WATER HEATER deemed revoked - GAS SYSTEM OUTLETS DISTRICT NO PR CESS�ED B LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi FINAL _ VALIDATION ness and Professions Code, and my license is in full force and DATE effect FINAL s�BS, License Number Lic Class BY cs Contractor Date I am exempt from the licensing requirements as I am a Plan check fee (f p licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ G�2 2 a / acting in my professional capacity (Section 7051, Bus mess and Professions Code) TOTAL FEE Q Lic or Reg No Date Plan check applicant HOME OWNER BUILDER DECLARATION Name*; �J ,f- I hereby affirm that I am exempt from the Contractor's IlAddress r License Law for the following reason (Section 7031 5, Busi CGty Tel No ness and Professions Code) 0,0 2 8 A ❑ I, as owner of the property, am exclusively contracting with licensedcontractors to construct the project # o'o?o`o o 5 (Section 7044, Business and Professions Code) 2 0 0 1 0 0 0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency o 0 0 1 Q 0 0 5 for the performance of the work for which this permit is issued (Sec 3097,Civ C) 0,b 2 2-8 1 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 authorize representatives of this County to enter upon the above entioned property for inspection purposes �</ Signilture of Permittee Date WORKERS' COMPENSATION DECLARATION 200002A6 DPW 4/87 APPLICATION FOR ,PLdJMBING PERMIT v a, I hrcGby,,,z f rm that I have a certificate of+consent to self in- 20 02 yure, or a certificate of Workers Compensation Insurance,or a CE 817(REV 8/86) 'certified cosy thereof (Sec 3800 Lob:C )� ,' a - ` Policy No /d Com an / _ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS, b r� D/ fP ❑ j----�-t�--1-- P Y t Certifi1 1 ed copy is hereby=furnished ft "^FOR APPLICANT TO FILL IN (PRINT OR TYPE) - BUILDING / D �R=C`_,� r F-1,.Certified copy is filed with the county building inspection= ADDRESS (0 e r , r p r ment NUMBER FIXTURE OR ITEM @ 'FEE M1 ,LOCALITY r " WATER CLOSET(TOILET) Date .1 Applicant `� NEAREST c CERTIFICATE OF EXEMPTION FROM WORKERS f BATH TUB CROSS ST t T t a COMPENSATION INSURANCE ( ' SHOWER ` fi OWNER„ (This section need'not be cornplefed if`the work mvoly"ed by y MAIL the permit is for one hundred dollorss(5100)or less ) LAVATORY r ADDRESS 3 Aj, Lw E9 Ly s a 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 - `. TEL•t`'NO r`os`to become subject to the Workers' Compensation Laws r- DISHWASHER CONTRACTOR r !� x- Date� ' Y `t`Apphi ant '" "' CLOTHES WASHER; ' t,-` X ' i G l ADDRESS NOTICE TO-APPLICANT If after making this Certificate>of Ex- SWIMMING POOL RECEPTOR emphon you should become subject to the Workers Compen LAN CITY sTEL NO 9 z sation provisions of the Labor Code,you must forthwith comp-, rA LAWN SPRINKLER SYSTEM' INV, L ` ` ly wi sucl provisions or this permit shall`be deemed revok- STATE LIC ed, I I 1, WATER HEATER LICENSE NO Z- CLASS - - f LICENSEDCONTRACTORSDECLARATION DISTRICT NO a OCESSED BY ' C GAS SYSTEM r' .OUTLETS I hereby affirm that I am licensed under,pr`ovisions of'CFapter , r s 9(commencing with Section 7000)of Division 3-of the Business OUTLETS OVER r eJ and Professions Code and my Iicense,is in full force and ef- 5 PER SYSTEM r FINA' VALIDATION fect v 17, r u as DATE O License Number y 71S Lic Class V ` J FINA U Ix Contractor Date - �> > B /; O 3^ I am exempt under SecLU B &P C for this reason Pian Check fee Date` PLUMBAG'PERMIT ISSUING FEE$ > a Signature � ,TOTAL FEE - fi `SINGLE FAMILY . HOME OWNER-BUILDER DECLARATION Plan',check applicant I liereby affirm that I am'exempt from the Contractor's License Name Law for the following reason,(Sect ion'7031 5,'Business,and, . Professions Code). r` _Address I as owner of tl e property, will do the work and theCity -Tel No r- �.structure is not intended or,offered'for sale(Section 7044 "1 99-26,3 9_26,3 A " Busmess,and Professions Code) r. - CONSTRUCTION LENDING vAGENCY,' r TM 3 1 ,o_o 4 0, .5 O N' I hereby affirm that there is a construction lending ogencyjfor „ i4 - r, �J o tKe performance of the work for which this permit is issued He r °'O'O 4 Q 5,0 50i (Sec 3097,`Civ C ) (� w 'i.�•O > r; .,v ' , . �,y L r.�, - r R� + n A�� {i' c,'�' ,k , 'qe <, x r . •r d,r a v� = dr ..d 0 3,29-88 Lender s Name Lender s Address ' e " PZ I certify that I have read this application and state that the s y, } > r 'i above mformation is correct I agree to comply with all County c_ ` ► r ordinances and State laws regulating Plumbing and hereby ), a 1 �ho representatives ofthisCounty to enter upon-the - z entio ed propert for'inspection purposes �- `SEE REVERSE FOR EXPLANATORY LANGUAGE ' rQ -- Siate ' u, j