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HomeMy Public PortalAbout10712 DAINES DR_Plumbing__ WORKERS't I hove a cerN DECLARATIONcorse APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667q , insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY ' Policy No.� Company 0 Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING / 7 Certified copy is Filed with the county building mspec- ADDRESS / � ��^— /✓C/1 U tion department. NUMBER FIXTURE OR ITEM C FEE �s LOCALITY Date Applicant ' WATER.CLOSET _ CROSSNEAREST. CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB COMPENSATION INSURANCE-. OWNER (This section need not be complete)ifthe work involved by SHOWER the permitis for one hundred dollars ($100)or less.) - LAVATORY MAIL -7 l/f ADDRESS �� /I.Z ti I certify that in the performance of the work for which this Permt is ssued, I shall not em - iiSINK CITY tiyl�G,L .tet employ any Person in .manner TEL NO. ,. l � C/! / so as to become subject to the Wo rs'Compensation Laws. DISHWASHER 3/�3��� CONTRACTOR Date Applican 4 CLOTHESWASHER ADDRESS NOTICE TO APPLICANT: If, after making t Certi icato-of Exemption, you should become subject the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Cod , you.must forth- CITY TEL. NO. LAWN SPRINKLER SYSTEM with comply with such provisions,or this permit shall be STATE LIC. 'deemed revoked. ' WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED Y I herebypffirm that I am licensed under provisions of Chapter 9 GASSYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER J o and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINALt2i, VAL ATION • ® Q DATE ^ >;License Number Lic. Class ra0 FIN U. Contractor DateEl BY 0.' I am exempt under Sec OU Bl for,this reason - Lal Plan check fee a Date: / N PLUMBING PERMIT ISSUING FEE$ ! Z Signature TOTAL FEE G , Plan check applicant :24 2 2 6 A SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name - #'a e 0-0 ° 5 I hereby affirm that I am exempt from the Contractor's License Address Low for the (allowing reason (Section 703).5, Business and '.F° ^ 1 650 Professions Code): City Tel. No. I, as owner of the property, will do the work and the structure is not intended Or offered for sale (Section D 'Q3, .3 _8 6 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 Nome 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 t ina rtes and State laws regulating Plumbing, and hereby aut orize representatives of this County to enter upon the It, e-mentioned'property for inspection purp0 es. SEE REVERSE FOR EXPLANATORY LANGUAGE 3 I /3/n Sig ure of Permittee Dole , WORKERS' COMPENSATION DECLARATLON APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A Insure, or acertificote of Workers'Compensation Insurance, CE':817.(REV. 10/81) or o.cerfifie o the (Sec. 3800, Lab.;C.�),r�} �,/r ❑ COUNTY OF LOS ANGELES BUILDING AND SAFETY Poiic No Company ` �Pl`Lr/l/ Certified copy is hereby furnished FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed.with the u y b 'ding inspec- - ADDRESS hon epartmenf NUMBER FIXTURE OR ITEM @ FEE .-� p LOCALITY .OZ9 4el.T WATER CLOSE � Date � Applicon NEAREST -• ' CERTIFICATE OF EXEMPTION FROM ORK BATH TUB CROSS ST. COMPENSATION INSURANCE arkinvolved • SHOWER _ OWNERS (This'se<tion need not 6e completed if th involvedby , the permit is for one hundred dollars,( 100)or lass:) LAvnTORv MAR C! certify that in theperformance of the work for which e ADDRESS �,., - permit is issued, I shall not employ any person in any manner SINK � � CITY EONO. NO. so as to become subject to the Workers Compensation Laws. DISHWASHER , CONTRACTOR 0 ' . Date Applicant CLOTHES WASHER ADDRESS Y C..�/ NOTICE TO APPLICANT: If, after making this Certificate of - �' LC' ©J _ 'Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the labor Code, you must.forth- CITY 1 El..LAWN SPRINKLER SYSTEM NO.920170/ with comply with such provisions or this permit shall be - STATE � LIC. // deemed revoked. WATER HEATER LICENSE NO. 3 /G'p CLASS L7`l LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under,provisions of Chapter 9 GAS SYSTEM y OUTLETS c(� (commencing.with Section 7000) of Division 3 of the Business' OUTLETS OVER and Professions Code, nd my license is in full force and effect. 5 PER SYSTEM d I�� ��% once �� VALIDATION O License Number— .&0 Lic. Class_ J6 r -1���rrr��' ppp C Contractor 0h iq�yT (` r2a imp, BY / � / �FINA ®' q W I am exempt under Sec. CL ro v 1011, 8.8P.C. for this reason Plan check fee Date:— .PLUMBING PERMIT ISSUING FEE$` - Signature TOTAL FEE sa SINGLE FAMILY Plan check applicant ' HOME OWNER-BUILDER DECLARATION Name EJ 8 2 6 A. I hereby affirm that I am exempt from the Contractor's License Add Law for the following reason (Section 7031.5, Business and °'s -w. . 5 Professions Code): City Tel. No. t ' ' ❑ I, as owner of the property, will do the work and the - .2 °'O CJ'8,�5 0 structure is not intended or offered for sale (Section o ° 4.F8 50.i 7044, Business and Professions Code). CONSTRUCTION LENDINGAGENCY . , - 0 6 0'7•=8 4 I hereby affirmthat 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 certify that ve read this application and state that.the above infor at' Ston is correct. I agree to comply with'oll County D 0rdinanc a d te laws regulating Plumbing,_ond hereby authori r pre tives of this County to enter upon the abov m ti ed Iii "-n pur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE E _ rj� ,G✓1 ign Lure a ittee Data