Loading...
HomeMy Public PortalAbout10629 DAINES DR_Plumbing__ WORKERS'COMPENSATION DECLARATION. Am® L ICATIO C • 1 hereby affirm that I have a certificate of coosent'lo self 76A67A FOR PLUMBING PERMIT , insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) - or a certified copy thgreof (Sec 3800, Lab.-C.) COUNTY OF.LOS ANGELES T, BUILDING AND SAFETY p3 .. W� ��- -- - Ocy Company Certified copy is here6-y furnished. FOR APPLICANT i0 FILL IN(PRINT OR TYPE) BUILDING r7 Certified copy is filed with the county building inspec- ADDRESS 1062q /�caes � D . tion department. NUMBER FIXTURE OR ITEM (2, FEE LOCALITYK/i— erry C' DateApplicant Awnlihimmic WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. - COMPENSATION INSURANCE • e r SHOWER OWNER MM1 A4gL:F, !1 (This section need not be completed if the work Involved by - �, -. �. D_// ff the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS 0. Q/y�Fj . I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK - CITY GL TEL.NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR L / ocles Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this CertADDRESSificate of 3 S W16Al ' Exemption, you should became subject to .the Workers' SWIMMING POOL RECEPTOR CITY'�'�.�cpr TEL. NO. Compensation'provisions pr the Labor Code, you must forth- LAWN SPRINKLER SYSTEM' - - "'��T GOJ�/•/A �� � with comply with such provisions or this permit shall be - STATE - LIC. deemed revoked., WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS'DECLARATION .•. DISTRICT NO PRQCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS . commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �`O;r >. and Professions Code, amd my�icense'is in full force and effect. 5 PER SYSTEM FINAL d VALIDATION O 'LS0�rL DATE •r� - V License Number T! 1/6 Lia Class p����� FINAL n Q Contractor L-r^•• — t^'�0�f Doted BY am exempt under Sec. d J o N B.BP.C. for This reason D Z' Plan check fee _ ' Dote: PLUMBING PERMIT ISSUING FEE$ , 6 'd Signature ' TOTAL FEE SQ - Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name 6 a`9 A I hereby affirm that I am exempt from the Contractor's License - - Law for the following reason (Section 7031.5, Business and Address - - #Is e.° e•s,5 Professions Code): City .Tel. No: t ❑ I, as owner of the property, will do the work and.tbe ,2 ° °.34.5'0 structure is not intended or offered for sale Section D 1' . 0 ° •.• 345 7044, Business and Professions Code). , CONSTRUCTION LENDING AGENCY _0 3—'8 3 1 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 D above.information is correct. 1 agree to comply with,all County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the - above- a tinned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE' , Signature of Perm' tie ' •pore r WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I he%Pby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 incur a ce�rt�if-iscate of Worker ' Compensation Insurance,• 76A667A, or a e ti c ��sJlf l9e�d. �00(��L�b}.(,'.�.J� )•.�n{� ,s COUNTY Of LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. — — Company 1) •,ln uDs As— _ Certified copy is hereby furnished. D1 t FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING' �Zernfi d copy is filed with the o y building inspec- ADDRESS' U.•�{/�LfL - horLd ppwrttpnl NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date S Applicant v• WATER CLOSET NEAREST C RTIFICATE OF EXEMPTION FROM WO ERS' BATH TUB COMPENSATION INSURANCE OWN (This section need not be completed If the work involved by SHOWER the permit is for one hundred dollars ($100)or,less.) LAVATORY MAIL r - . ADDRE I certify that in the performance of the+work for which this , permit is issued, I shall not employ any person in,any manner SINK CITY TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER ` CONTRACTOR Date 'Applicant CLOTHES WASHER - NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS Exemption, you should become subject to the 'Workers' SWIMMING POOL RECEPTOR - CITY . - Compensation provisionspf-the Labor Code, you must forth- LAWN SPRINKLER SYSTEM !! with comply with such provisions or this permit. shall be STATE , -7 deemed revoked. WATER HEATER LICENSE NO. CLASS - LICENSED CONTRACTORS DECLARATION DISTRICT _ • P ESSED BY I hereby affirm Ihot I am licensed under provisions of.Chapter 9 GAS SYSTEM - OUTLETS �` O (commencing with Section 7000) of Division 3 of the Business O LETS OVER ((JJ } and Professions Code a(((�n(dd my license is in full forceandeffect.• ER SY EM FINAL AL1 ATION 6: License Numb Lic. Class • •S �' .FINAL Contractor Date FI 0 ❑ O, I am exempt under Sec W 'B.BP.C. for this reason -- .. n. - - Plan check fee D - - Z Date: PLUMBING PERMIT ISSUING FEE$ yi Signature ..._ TOTAL FEE 1, - Plan check applicant " SINGLE FAMILY c- HOME OWNER-BUILDER DECLARATION Name ' 1 hereby affirm that Iam exempt from the Contractor's License Low for the following reason (Section 7031.5, Business and Address - ' .Professions Code): City Tel. No. - 33W ❑ I, os owner of the property, will do the work and the 1 ITEEM�] structure is not intended or offered for sale (Section _ 7044, Business and Professions Code). © - - TOTAL 32: 00 CONSTRUCTION LENDING AGENCY C;HE{';K I hereby affirm that there is a construction lending agency for - the performance of the work for which this permit is issued CHANGE .Ut' (Sec. 3097, Civ. C.). - Lender's Name Lender's Address 1 AM 111:]( 1 certify that I he read this application and state that theD above informatioavn is correct. I agree to comply with all County - ordinance o d State lows regulating Plumbing,.and hereby. authoriz re esentatives of this County to enter upon the ' abov�tey for inspection ur aces. ' SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee - Dgifte :.. _ D.B.B.1T asw acre 1-�B 1 APPLICATION FOR PERMIT ,DEPARTMENT OF BUILDING AND SAFETY �� � � COUNTY OF LOS ANGELES WM. J. FOR,CHIEF ENGINEER .NATURE OF INSTALLATION DISTRICT O. G moo// P o ©P RMIT 1 O. ROUGH FI%TU REB COMPLETE HEATER CE86POOL I BEPTICTANK sT RECEIVED 8Y READY FOR ' DATE188UEO GAS I I MIBCELLANE UB 1 0 A PIRBTJNBPEC710N APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY JOB' 0 •NAME ADDRESS _ / A /}n -0 f hS-/L 0 ADDRESS LOCALITY L _ NZAS LL .CITY / `� J TEL.No. ~ CR060 COUNTY - - � CERT.No. -EXPIRES NS 'NAME LOCATION-OF SEPTIC TANK, OR CESSPOOL: 2 MAIL 3 ADDRESS NORTH O 1�— CITY' TEL.No, IAM THE LEGAL POSSESSOR OF THE ABOVE LOB ANGELES COUNTY CERTI TSE OF 011ALI�ICATION. !/Ay (rCCPLU9/O//7 1 AM THE LEGAL OWNER OF THE PROPERTY DESCRIBED ABOVE. )'i^• A Ir OWNER Ir CORRECTIONS ✓.Srii�G� "S A.r-1 G�sc-.YPodL SOUTH - J DESCRIPTION OF WORK z __/ BATH TUB FURNACE R' -SHOWER -DISHWASHER _ D / LAVATORY REFRIGERATOR KITCHEN SINK WATER SOFTENER - - FLOOR BINK BANDTRAP GLOP SINK FLOOR DRAIN WAeH TRAY URINAL APPROVALS / WATER CLOSET DRINKING FOUNTAIN _ �rDATE ) /L N�aPBCMR'9 NAME - 1 WATER HEATER , DENTAL LAVATORY ROUGH PLUMBING METES �• GAB ODA FOU NTAIN OUTL OAS PIPING GAB VENT CESSPOOL .I I 7.TOTAL NUMBER OF FIXTURES ,f SEPTIC TANK CESSPOOL 'aEPTICTANK -' y V SEWER -S UTILITY CO,NOTIFIED I 1;r TOTAL FEE FINAL r Fi D.B.B.17 RSM BETE I­U1 - APPLICATION FOR PERMIT DEPARTMENT OF BUILDING AND SAFETY COUNTY OF LOS ANGELES IPWAS 0m� WM. J. FOX. CHIEF ENGINEER NATURE OF INSTALLATION DISTRIC<NO. O UP o f PERMIT NO. ROUGH FIXTURES COMPLETE J (.. NEATER CESSPOOL I—I SEPTIC TANK RECEIVED sY7 READY FOR DATE ISSUED FIRST INSPECTION ? _ AB MI CELLANEOUB ✓/✓I/V APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY d. NAMHJOB � /gL.�-• - )� ADDRESS 3/5 $ ADDRESS _J 1 �Y�"T/ /I✓1� /�n N.J. LOCALITY - J �F C,-/TEL. / - / NEAREST d CITY A .Jt ��... i JTEL.No. CROSS ST. COUNTY CERT.No. f ./EXPIRES" m NAME / LOCATION OF SEPTIC TANK, OR-CESSPOOL 2 MAIL NORTH ADDRESS AA O Cin p �� IL.I �,• ' A ..Y/V{• 1 l 1�1TI'. TEL.No. 1 AM THE LEGAL POSSESSOR OF THE ABOVE LOS ANGELES COUNTY CERTIFICATE OF QUALIFICATION. PLUMBER 1 AM THE LEGAL OWNER OF THE PROPERTY DESCRIBED ABOVE. Y OoWNER /f CORRECTIONS BOUTH J DESCRIPTION OF WORK Z,> BATH TUB FURNACE HOWBR DISHWASHER � LAVATORY REFRIGERATOR _ KITCHEN BINK WATER SOFTENER - FLOOR SINK BAND TRAP ._ SLOP BINK FLOOR DRAIN - WASH TRAY URINAL APPROVALS WATER CLOSET DRINKING FOUNTAIN DATE" INSPECTOR'S NAME WATER HEATER DENTAL LAVATORY ROUGH PLUMBING METER—GAS SODA FOUNTAIN GAS PIPING I I n OUTL GAS VENT TOTAL NUMBER OF FIXTURES' �� I� -/ SEPTIC TANK _CESSPOOL SEPTICTANK SEWER B L/ unun co.NOTIFIED f7,7_3, - .TOTAL FEE7� FINAL