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Home My Public Portal About9826 DAINES DR_Plumbing__ WORKERS'COMPENSATION DECLARATION 78A887A APPLICATION FOR PLUMBING PERMIT , I hereby affirm that I have a certificate of consent to self ce s+r (z-eo) insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C.) COUNTY OF LOS ANGELESBUILDING AND SAFETY Policy No Company �, Certified • copy is hereby furnished. - FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING Certified co NUMBER FIXTURE OR ITEM • FEE ADDRESS /V��•' �• copy is filed with the county building inspection • department WATER CLOSET LOCALITY Date Applicant NEAREST BATH TUB CROSS ST L � v ` • CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER MAIL LAVATORY ,r } (This section need not be completed if the work involved ADDRESS �7— D/ Al — Y a by the permit'is for one hundred dollars ($100) or less.) SINK C I T V TEL NO OU `L� LFC� I certify that in the performance of the wo r which this DISHWASHER permit is issued, I shall not emplo any pe on i any m net CONTRACTOR L�E e 1 Q so as to become subject to t orkers' om ensatio aws CLOTHES WASHER ADDRESS-- 6 �� A -W Date% /o��Applicant , SWIMMING POOL RECEPTOR a NOTICE TO APPLICANT • after making this Certificate of CITY N G LTEL NO tl c N Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATELIC Compensation provisions of the Labor Code, you must forth- WATER HEATER LICENSE NO A `�(/1� � CLASS with comply with such provisions or this permit shall be .- . deemed revoked GAS SYSTEM ` OUTLETS DISTRICT NO P CESSED BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Bus+- FINALj7� VALIDATION ness and Professions Code, and my license is in full force and DATE f Q effect r FINAL) License Number / Lic Class BY, -� Cbfitfac 0-f o Date A9 I am exempt from the licensing 'requirements as I am a Plan check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE C/ Lic.or Reg No Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name Address I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Busi- City Tel No ness and Professions Code) I, as owner of the property', am exclusively contracting with licensed contractors to construct' the project (Section 7044, Business and Professions Code) ;92566A, CONSTRUCTION LENDING AGENCY # o o•o o 9 5 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is2 0 0 Q Q issued(Sec. 3097,Civ C.) - Lender's Name o 'o - 1,0,006, Lender's Address I Q l'0i 8 I certify that I have read this application and state that the above information is corr t Iagree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and St laws regulating Plumbing, and hereby auth ze repre tatives oft this County to enter upon the a e-mentio d propertyfor ection purposes /0 -/o Signature o-T Permittee Date r WORKERS'COMPENSATION DECLARATION 1z (z-eo)a cE'8 onsent to selfAPPLICATION FOR PLUM'BING PERMIT ,, I-hereby affirm that I have a certificate of c ; ce i insure, or a certificate of Workers'-Compensation Insurance,or a certified copy thereof(Sec-3800,Lab.C) " COUNTY,OF LOS ANGELES BUILDING,AND SAFETY Policy No 'Company M Certified copy is hereby furnished., FOR APPLICANT TO FILL IN•(PRINT OR TYPE) BUILDING Certified copy is filed with he c city buil ng nspection NUMBER FIXTURE OR ITEM • FEE ADDRESS _ LOCATY LI /,G rc. Datedela Applicant A WATER CLOSET NEAREST ' BATH TUB CROSS ST �� 0,' CERTIFICATE OF X PTION FROM WORKERS' �77SHOWER -� OWNER COMPEIIfyXTION INSURANCE MAIL / (This section, need'not.be completed,if the work involved LAVATORY ADDRESS �j1tp �. / /� by'the permit is•for' one' hundred dollars'($T00) or less.) t` SINK' CITY TEL' NO I certify that in the performance of thewwork',for which this, DISHWASHER permit'is issued,,I shall not.employ any person in-any manner CONTRACTOR �'� G/ �J cc so as to.become subject to the,Workers' Compensation Laws. '. CLOTHES WASHER �/ 0 ADDRESS CJ -Applicant rSWIMMING POOL RECEPTOR U NOTICE TO APPLICAN-T'' If; after,making'this Certificate of CITY ��jf� TEL NO �35,2 a, Exemption, you should become subject',to the'Workers'; LAWN SPRINKLER SYSTEM rn Compensation provisions o8'the Labor Code;you must'forth- STATE LIC p/ Z WATER HEATER - -�'-• LICENSE NO. 7 CLASS`_J�y with comply with such provisions, or this permit'shall be % .. DIST CT NO. •PR CESSED BY" GAS SYSTEM OUTLETS deemed revoked _� Q LICENSED CONTRACTORS DECLARATION•' OUTLETS OVER Ov I hereby affirm that-I am licensed under provisions of Chapter` 5 PER SYSTEM 9'(commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATI ness and Professions Code, and my license is m'full force and DATE If effect FINAL License Nurh r Lic'Class BY Contract Date ❑ I m exempt from the licensing requirements,as I am-a Plan check fee licensed architect or a -registered professional engineer PLUMBING PERMIT ISSUING FEE$ 'acting)n my professional capacity (Section 7051, Bus- - ` iness'and Professions Code). i k TOTAL FEE g Lic or Reg.No. Date Plan check applicant >;•'•1 s HOME OWNER-BUILDER DECO` RATION 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 ness and Professions Code) ❑ I .• , as owner of'the property, am exclusively contracting � < -with licensed contractors to`construct the, project (Section 7044,"Business and Professions Code). 2 Q 5$ A, CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency a,# 0'0-0 o.0 5 4 for the performance of the work •foi• which this permit,is 2 0 0 2 0 Q issued (Sec. 3097,Civ.C) Lender''s Name t, o ° 25005 . Lender's Address - 0,c i1i 0�-�8 0 I certify that I have read this application and state that the T above information is correct.I agree to comply with all County SEE REVERSE FOR-EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby author ze-re esentat o is County to enter upon the ab ov - en oned erty for i spection purposes vYro' gnature f m Perittee a y•