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Home My Public Portal About6632 CLOVERLY AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION _ p p 0 �n I hereby affirm that I have a certificate of cd.i5ent to'self' 76A667A Y , - 7 R ��L��OuV FOR I�L�VIIV'111��11V� Il��I1�UVll�� insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 1W81) or o certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. - Company ❑ Certified copy is hereby furnished. F-1FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING • Certified copy is filed with the county building inspec- ADDRESS aZr FIXTURE OR ITEM tion department NUMBER @FEE LOCALIT WATER CLOSET.. Date Applicant 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 IN the permit is for one hundred dollars,($100)or less.) LAVATORY ADDRESS • I certify that in the performance 'of the work for which this permit is issued, I shall not employ any person in any.manner SINK CITY TEL. NO. so as to become subject to the Workers'Co ensation Laws. DISHWASHERrN CONTRACTOR , � '. Date Applicant ! ^ CLOTHES WASHER ADDRESS' 1 ^ NOTICE A LICANT: If, after makin this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers CITY TEL. NOS` Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. r(' deemed revoked. WATER HEATER LICENSE CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRO SSED BYE I hereby affirm that i am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (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 J O �0��`` — i DATE ( VALIDATION "` License Number Lic. Class --_� � FINAL Coniractoj��a Date BY r--✓ d r`r. V ❑ I am exempt under Sec. B.BP.C. for this reason Plan check fee D V y/'6 Date: PLUMBING PERMIT ISSUING FEE Signature TOTAL FEE —,V Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I`am exempt from the Contractor's License Address 9'9.a,9 A Low for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. ;loo-o'o 0 5 ❑ I, as owner of the property, will do the work and the 1 °'o G aF5 0 'structure is not intended or offered for sale '(Section 7044, Business and Professions Code). D 0,0 o 2 8 5 p`s CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for 0222-83 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 D 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 dbpve-mentioproperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o rmittee Date WORKER'S COMPENSATION DECLARATION 76A666DPW9/89 APPLICATION FOR PL�UIIMIIBIII�'1G PERMIT � 76A667A I�"L� LSO I hereby affirm that I have a certificate of consent to self'insure,'v - or a certificate of WorKer's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company� ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR.TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESS T part ent. r NUMBER FIXTURE OR ITEM @ FEE r LOCALITY 1 Dat Applicagj„ 'do ' WA7ER,CLOSET NEAREST CROSS ST. 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 PAGE PARCEL permit is for one hundred dollars($100)or less.) OWNER LAVATORY I certify that in the performance of the work for which this permit is issued, I shall not employ any,person in any,manner so as to SINK MAIL IL become subject to the Workers'Compensation Laws. ADDRESS6 16 DISWASHER CITY TEL.NO , Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTO Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY EL. 5�0 } I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER Q (commencing with Section 7000 of Division 3 of the Business and STATE LIC. ( 9 ) LICENSE N � CLASS G (� Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS OUTLETS OVER DISTRIC7 �� PROCE O,, 5 PER SYSTEM License Number �� L_ic.Class FINAL� "[ VALIDATION UJ DATE ('��t./' •: COCL ❑ i FINAL �4' 7 .._' .i•n ii Z I am exempt under.Sec. BY B.&P.C.for this reason Plan check fee , Ffsr Date:' PLUMBING PERMIT ISSUING FEE$ Signature (fi C/ l TOTAL FEECHECK SINGLE FAMILY Plan check applicant AL '�f. _ 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 _.. Code): ❑ City Tel.No. 010 I'D-ws _ _ 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.) 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-menti ned property for i �sspA�ho rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Ignature of Permittee Da