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Home My Public Portal About4515 ELLIS LN_Plumbing__ WORKERS'COMPENSATION DECLARATION APPUCG VMN FOR PLUM o MG PERMT 1'here�'by uffirm that I have a certificate of consent to self 76A667A insu 4 or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) oI a,certified co y thereof Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES. BUILDING AND SAFETY �—� LL S • I�¢rA�lo11 Policy No. Company ILQ� Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS L f�A2 tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY 31 h 3-� t WATER CLOSET Date Applica NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER s)fL-,�e-_ (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO, so as to become subject to the Workers Compensation Laws. DISHWASHER CONTRACTOR C 1 �•� Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making'this Certificate of �.• C>�AtV�Se t �=+lu C�`J Exemption, you should become subject to the Workers' SWIMMINGPOOL_RECEPTOR CITY TEL. NO.L` Compensation provisions of the Labor Code, you must forth_' ��_i✓v1 13'�-l1 LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE `, Qy ry LIC. , deemed revoked. WATER HEATER LICENSE NO. e S ( rte / CLASS T LICENSED CONTRACTORS DECLARATION DISTRICT 5 P CESSED BY GAS SYSTEM OUTLETS J 1 hereby affirm that I am licensed under provisions of Chapter 9 ` �" /a (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ' VALIDAIVON V _29(f'7 �7— Lic. Cla License Number _ ss c J� ��2_ -1 1—t: BN O Contractor Date G I am exempt under Sec. �l �• B.&P.C. for this reason D Plan check fee. • Date: PLUMBING PERMIT ISSUING FEE$ (} 2.1 6 8 0 A Signature TOTAL FEE v #'o'0 0 0,0 5 Plan check applicant `O:° 3 Q.-5 0 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name o'o o 3 Q 5 0 6 I hereby affirm that I am exempt from the Contractor's License Address O 2 13"85 - Law for the following reason (Section 7031.5, Business and 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 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 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-men _rfed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE "Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 76A667A hereby affirm that I have a' certificate of consent to self ce fin (2-60) A P P L I C A T 0 O CI FOR P L u M B I N G PERMIT sure,.or a certificate of Workers'Compensation Insurance,or certified copy.t ereof(Sec. 3800,Lab.C.) � _ �(-[�� fid{'� � � COUNTY OF LOS ANGELES BUILDING AND SAFETY ; iolicy N� Z`7 Company / Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) [NEAREST DING ESS S Certified copy is filed with't count ilding inspection NUMBER FIXTURE OR ITEM O FEE l de ar a WATER CLOSET LITY � ��C )ate-� � Applicant �� LDBATHTUB V� S ST. i CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER LAVATORY MAIL 7� / � A This section need not be completed if the work involved Z 3� �`� ADDRESS ® s 00. [This permit is for one hundred dollars ($100) or less.) SINK a Utz CI1sY "'�-� TEL.NOa$'"� "�d-/ O I certify that in the performance of the work for which this DISHWASHERU 15 Od CONTRACTOR perm4issued,,•I shall not:employ any person`in anymanner atYso asc a subject to the Wo rs' Compensation Laws. 60 1 CLOTHES WASHERltid C1ADDRESS /+Date Applicant= SWIMMING POOL RECEPTOROTAPPLICANT: If, of making this rtificate of CITY = l�aWTEL. NO. — a Exemption, you should beco a subject to.the Workers' LAWN SPRINKLER SYSTEM STATE r LIC. /� Compensation provisions of the Labor Code, you must forth- LICENSE NO. ! /`/ CLASS [/�� 1 .�� with comply with such provisions or this permit shall be WATER HEATER deemed revoked. 41 GAS SYSTEM OUTLETS A -� DISTRICT NO. PR CESSED B LICENSED CONTRACTORS DECLARATION OUTLETS OVER lJi � 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 ness and Professions Code, and my license is in full force and DATE j / VALIDATION effect. _ 1 1 /� 1� FINAL License Num erl 7-r / Lic.Class � m BY ontractor Date h ) F aI exempt from the licensing requirements as I am a Plan Check fee license chitect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ crf acting in my essional capacity (Section 7051, Bus- iness and Professions t TOTAL FEE _ 07 !J D Lie.or'Reg.No. Plan check applicant HOME OWNER-BUILDER DECLARATION Name/+JE pZX� �A.,7e je. ,Is 93?��' `� �5 21.4 A I hereby 'rm that I am exempt from the Contractor's /address '� License Law for Ilowing reason (Section.7031.5, Busi- City �c` L ��it d T.I.No.V'6 �� # o.o o o o rj ness and Professions Code I, as owner of the property, am a usively contracting 2 - 1 ,8 7'0 0 with licensed contractors.to const ruea project o•o _ (Section 7044, Business and Professions Code 1 8 7 0 0 c7 CONSTRUCTION LENDING AGENCY Jr 1 1 H 1 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097 i}z"C�)3, i Lender's Name fd 6'✓ �i�y a� �Lender's Address S'�. . I certify that I 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 authoryt8 representatives of this County to,enter upon the ,ab ov m do ed property for inspection pur oses. - . Siignatuieof Permiftee D to