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HomeMy Public PortalAbout4908 DOREEN AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION I APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A - R. insure, or a certificate of Workers' Compensation Insurance„ CE Bp(REV. 10/51) or a certified copy thereof (Sec. 3800,Lab. C.) COUNTY OF LOS ANGELES �� BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING O O tion iepartme is filed with the county building inspec- ADDRESS O tion department. _ NUMBER FIXTURE OR ITEM Q FEE LOCALITY �' Date Applicant WATER CLOSET 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 Det I J Auld the permit is for one hundred dollars ($100)or less.) LAvgTORv ADDRESS MAIL I certify that in the performance of the work for which this /^ permit is issued, I shall not employ any person in any manner SINK CITY TEL NO. D so as to.become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Doteg-- Applicant CLOTHESWASHER ADDRESS S V.12 s NOTICE TO APPLICANT: If, after making this Certificate f' SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL. NO. c �� Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM v with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. /D CLASS LICENSED CONTRACTORS DECLARATION / DISTRIC NO. P CESSED By I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is Tri full force and effect. 5 PER SYSTEM FINAL Q VALIDATION 0. �ps DATE License Number V I Lic. Class Ad V n FINAL CContractorDate�"r�J y BY � Q ❑ am exempt under Sec. 1/3CA" B.BP.C. for this reason Plan check fee ® Z Date: - PLUMBING PERMIT ISSUING FEE$ Signature /- s U TOTAL FEE & 3753A Plan checkapplicant SINGLE FAMILY o e e o 0 5 HOME OWNER-BUILDER DECLARATIONName 1 , I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address 2.ee Q50 Professions Code): City❑ Tel. No. oto e 1 6 5 O l U I, as owner of the properly, will do the work and the r structure is not intended or offered for sale (Section 0823784 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 lows regulating Plumbing, and hereby ' authorize representatives of this County to enter upon the above-mentioned property f r i pec ion purposes: SEE REVERSE FOR EXPLANATORY LANGUAGE sf ignature of Permittee Date- - WORKERS' COMPENSATION DECLARATJL^fd ;. :...;._. APPLICATION FOR PLUMBING PERMIT I hereby affirm that I-have a certificate of c/bnsent to self 76A667A insure, or a certificate.of Workers' Compensation,lnsurante, CE-817(REV. 10/glj or a certified copy (hereof (Sec. 3800, Lab. C.)' COUNTY OF LOS ANGELES 7/ / BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. ❑ FOR APPLICANT 10 FILL IN(PRINT OR TYPE) BUILDING /J GJ// © � _ f _ Certified copy is filed with the county building inspec- ADDRESS % eS ��/ tion department NUMBER FIXTURE OR ITEM @ _F E LOCALITY / •�� WATER CLOSET Date Appli4ant NEAREST ` CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB - COMPENSATION INSURANCE SHOWER OWNERD* !J/rt \ A�fS V (This section need not be completed if the work involved by MAIL — / the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS (4 b+F/ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY _ TEL. NO �j so as to become subject to the Workers Compensation Law r Y7/P ' ' �l� �/ ��/ DISHWASHER CONTRACTOR Date Applicant v 4/ �( _� .�•�— CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate );f S'y �Q /q eh J Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITYTP/� J,7/y —1;f%J TEL. NO�{`7 G�7 3 LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE' �'/f© ! / LIC. J� deemed revoked. WATER HEATER LICENSE NO. _ ;/ ( CLASS ,/G LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ' (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER Sx or d and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL �/�/L VALIDATION O License Number _ Lic. Class DATE 'JN� V Contractor z /-�'� 61J( Date 2' 1—SZ UBY FINAL V ❑ I am exempt under Sec. B.BP.C. for this reason G ? Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ (� So Signature TOTAL FEE S0 °389,4 Plan check applicant SINGLE FAMILY - "e,^•nt�•O HOME OWNER-BUILDER DECLARATION Name a o 0 �2Gs Qx 5 I hereby affirm that I am exempt from the Contractor's License ` t Law for the following reason (Section 7031.5, Business and Address 0 7 31.._84 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 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-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKER'S COMPENSATION DECLARATION 2MG2 DPW 9/89 APPLICATION FOR PLUMBING PERMIT }(fI IIS 1 hereby affirm 76A667A that I hare a certificate of consent to self insure, L1 or a certificate of Worker's Compensation Insurance, or a certified copy$hereof?Sec.3800 Lab. C.) 0 � , COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No. Company L Q Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING / P0 �._.r(i� tw`� Certified copy is filed with the county building inspection ADDRESS L ) (� department. NU ER FIXTURE OR ITEM @ FEE LOCALITY_ Dale Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS OR I COMPENSATION INSURANCE BATH TUB ASSESSOR Q pp,,z( (This section need not be completed if the work involved by the SHOWER MAP BOOK V W PAG E(JWD PARCE permit is for one hundred dollars($100)or less.) OWNER I certify that in the performance of the work for which)his.permit SINK ADDRESS LAVATORY lTN is issued, I shall not employ any person in any manner,so as to MAIL !, I . G L 'G r+ry become subject to the Workers' Compensation Laws. /'�' DISWASHER CITY C; TEL.NO (� C,� ✓✓ Date Applicant CLOTHES WASHER CONTRACTOR ( r `� � NOTICE TO APPLICANT: If, after making this Certificate of 'p -s ,J.y�J C.. Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS,P -IQOX, G64kaq provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM 'C LICENSED CONTRACTORS DECLARATION CI L NOS? I hereby affirm that ) am licensed under provisions of Chapter 9 WATER HEATER �! 1C�0. d (commencing with Section 7000) of Division 3 of the Business and STATE -- LIC. O Professions Code,and my license is in full force and effect GAS SYSTEM OUTLETS LICENSE NO. CLASS V OUTLETS OVER DISTRIC � PROCESSED BYO 5 PER SYSTEM License Number Lic.Class .. H /�1/'�r�(('�/� /' FINAL / VALIDATION ,. ,.`_ W Contractok-Y^`�1>r-O)"d f L I DateFI ` DATE Z_2�- a I IYi`t` 1 am exempt under Sec. FINAL Z BY —8 154 B.BP.C.for thiseason _ o _l D '_. Plan check fee ® CHECK PLUMBING Signature Z • PLUMBING PERMIT ISSUING FEE$ 24p Lf p f:rr�'r�,i?)3C •"I-I ❑ TOTAL FEE - Plan check applicant _j`lj Irl-j 11 Ij E_ SINGLE FAMILY HOME OWNER-BUILDER DECLARATIONName ;=. ?7`7 '. �t- 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. I,.as owner of the property,will do the work and the structure is not intended or offered for.sale (Section 7044, Business I and Professions Code). CONSTRUCTION LENDING AGENCY - I hereby affirm that there is a construction lending agency for the - performance o7 the work for which this permit is.issued (Sec. 3097, Civ. C.) Lender's Name ' Lender's Address certify that I have read this application and state that the above - information is correct.�.I agree to comply with all County ordinances and S to lawsregulating Pluinrg. and hereby authorize repres ntatives o is County tom ter upon the abovemenlioned pr�forinion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per ttee Date rT