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Home My Public Portal About10626 DAINES DR_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION ImP IC A TION IC®ID PLUMBING flpAlDIlaARo fm f2RMIT - I hereby affirm that I have a certificate of consent Id self �7A P11�I�IL '�.r,P'i 0 USI I� IM1 I�IL'1.YYVGID 0�1'�Y I�IG II'lGN9 II insure, or o certificate of Workers' Compensation Insurance, SCE 817(REV. 10/81) or a certified �(copy �the�reeoff Sec. 3800, b. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY 416 P❑ Certified copy is hereby furnish allcyN /�ie �G-� "Cbmpany '� _ ed. ❑ - FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS JAIi tion department. NUMBER FIXTURE OR ITEM r FEE LOCALITY Date C L �/ �C� ' �L Applicant �� WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM ORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER SHOWER (This ermi i nerd not be red dolga if the work involved by MAIL _ the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS -11-17 le— I certify that in the performance of the work for which this permit is issued, I shall not employ any person'm any manner SINK CITY TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER H — I CONTRACTOR Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of — ADDRESS GPOOL RECEPTOR f�Qd� Exemption, you should become subject to the. Workers' Compensation provisions of the Labor Code, you must forth- - .CITY LAWN SPRINKLER SYSTEM ! TEL N /0`6 �V G v with comply with such provisions or this permit,sholl be STATELIC. deemed revoked.. WATER HEATER LICENSE NO. Z CLASS _ LICENSED CONTRACTORS DECLARATION DISTRICT PROCES ED BV I hereby affirm that I am licensed under provisions of Chapter'9 - GAS SYSTEM OUTLETS . (commencing with Section 7000) of Division of the BusinessOUTLETS OVER Y and Professions Code,and my license is in full force an effect., 5 P SY EM _ FINAL 4 �.,�7 0 / ^�./_.gf• / VALIDATION O O► DATE I u TCJ License Number�Lic. Class fY FINAL O Contractor Date BY BY „'C1 V ❑ IL I am exem under Sec. d N 8.8P.C. for this reason Plan Ch@CIC fee D Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL Fee Oro _ Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Nome T( 6 I:hereby affirm that Iamexempt from.the Contractor's License Address Low for the following reason (Section 7031.5, Business and u�d� - Professions Code): City Tel. No: ❑ 4 as owner of the property, will do the work and the structure is not'intended or offered for sale (Section D 7044, Business and Professions Code). - r O 7 �,A CONSTRUCTION LENDING AGENCY • hereby affirm that there is aconstruction lending agency for the performance of the work for which this permit is issued. > (Sec. 3097, Civ. C.), - 20-o 1 (x 5 O Lender's Name o o,,/o•1 6 5CD o M Lender's Address ,0 Q.2 5-8'41, 1 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 above- -entioned property for pecti purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE. Signature of Permi eco--T� Data ' WORKERS'at I have A ION DECLARATION 76A66 APPLI.CATI;ON FOR PLUMBING PERMIT 1 hereby affirm that I have a certificate of cony�it to sclf ce el insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) .e ' COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT.OR TYPE)❑ BUILDING '®ADDRESS Q Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM C FEE. r— . I department. WATER CLOSET LOCALITY Date Applicant , I J NEAREST BATH TUB y CROSS ST.__I� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER !� OWNER MAIL (This section need not be completed if the work.involved LAVATORY ADDRESS ESS �' by the permitis for one hundred dollars (5100) or,less) - } BINK - CITY. TEL.NO. _ 0 1 certify that in the performance.of the work for which this DISHWASHER - t 'U. permit'is"issued, I shall not mploy any person in any manner CONTRACTOR so as [ bre�c me subjzct to a orke s` mpinsation Laws. - CLOTHES WASHER ADDRESS % 0- Date cT pplica SWIMMING POOL RECEPTOR U NOTICE,TO AP LICANT: If, after m mg this Certificate-of CITYTEL.NO..S W Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM P STATE `` LIC. ( W Compensation provisions of the Labor Code, you must forth-. LICENSE NOK. CLASS v z with comply with such provisions or this permit shall be WATER HEATER deemed revoked. GAS SYSTEM OUTLETS- DISTRICT NO.. PRO EBBED BY _ 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 ( > ' s9 VALIDATION ness and Professions Code, and my license.is in.full.force and DATE r}.(3 J` effect. , AO _ FINAL ( LicenseN ber .Lir. Class BY Contractor Date I am exempt from the licensing requirements as Iam 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 Lic.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. - 95 826 A ness and Professions Code): , I, as owner of the property, am exclusively'contracting - # e ee,e e 5 with licensed contractors to construct the .project - (Section.7044, Business and Professions Code). 2�a a 3.25 CONSTRUCTION LENDING AGENCY3L SOiv I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is QI 2A;S 2 issued (Sec. 3097.,Civ.C.). Lender's Name Lender's Address I certify that 1 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 ve-mentioP`e\ roperty for inspection pµ`r�rpros^es. Signature o ermt[tee Date