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Home My Public Portal About4523 ELLIS LN_Plumbing__ WORKERS' COMPENSATION DECLARATION4=AI�l!"1�0�lr-d�0 N FOR PLUM °o QMI IG U"ER T d heredby istfi?m that I have a certificate of consent to self 20-0026 DPW 6/87 i7sure,'or a certificate-of Workers' Compensation Insurance, 76A667A or o certified copy thereof (Sec. 3800, Lab. C. COUNTY•OF LOS ANGELES DEPT.OF PUBLIC WORKS Policy No, Company , Certified copy is hereby furnished. BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS S S L-RN Certified copy is filed with the county building inspec- tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY `q/r7 Date Applicant 2— WATER CLOSET NEAREST G'`r 7Y CERTIFICATE OF EXEMPTION FROM WORKERS' j BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER �� (This section need not be completed if the work involved by MAIL 452V �L LAS, the permit is For one hundred dollars ($100)or less.) LAVATORY ADDRESS c_�-[ r✓ I certify, that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK �. CITY�E� � 171-/-Y TEL. NO. so as�to bcomesubject to the Workers'Compensation s. DISHWASHER CONTRACTORDate2 Applicant CLOTHES WASHER �- NOTIC TO PPLICANT: If, after m king this Certificate of ADDRESS �,5'4 /E��- L 17-,V Exemption, you should become •subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITYTE�hLt �/' TEL. NO. with comply with such provisions.or this permit shall be STATE p p LIC. deemed revoked. WATER HEATERn LICENSE NO. �7 aCLASS LICENSED CONTRACTORS DECLARATION V DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Cede,and m license is in full force and effect. 5 PER SYSTEM C-Q p Y FINAL VALIDATION Ll.� License Number �•�% o/�7 Lic. Class el_ � Q� ��83 pZ� (, DATE z—�--� 1L 0, License Q FINAL Contractor��"c-uq Date BY o, ❑ I am exempt under Sec. O� W B.&P.C. for this reason Plan check fee Z Date: PLUMBING PERMIT ISSUING FEE$ Signature ' TOTAL FEE Plan check applicant SINGLE FAMILY - HOME OWNER-BUILDER DECLARATION Name I hereby.affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address - �e Professions Code): City Tel. No. -••-= xi-- ❑ 1, as owner of the property, will do the work and the ) ,i`•�: structure is not intended or offered for sale (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY r"•i.c"'El 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 I IJ-;y - i- _ Lender's Address - f ;;n 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 for 'nspection purp es. /j n/) SEE REVERSE FOR EXPLANATORY LANGUAGE Tign ure of Permittee Dqle WORKERS'COMPENSATION DECLARATION, Ap PFUCAp YP0N( FOR U"LUl1VlIMG 1!- E MT I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers' Compensation Insurance, 76A667A .or a certified copy thereof (Sec. 3800, Lab. C,) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Pal N0 eel-6-91 Company 4r�T� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) 'BUILDING 17Certified copy is filed with the county building inspec- ADDRESS S �� 1//Vtion department: UMBER FIXTURE OR ITEM @ 'FEE LOCALITY (/Date Applicant �-�°' "�� WATER CLOSET NEAREST42 CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. s-t4 COMPENSATION.INSURANCE OWNER SHOWER 4 ! (This section need not be completed if the work involved by, MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued; I shall not employ any person in any manner SINK CITY ; rte TEL. NO. so as to become subject to.the Workers'Compensation Lo s. DISHWASHER CONTRACTOR Date i Applicant CLOTHES WASHER ADDRESS d � NOTICE TO APPLICANT: if, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR � Compensation provisions of the Labor Code, you must forth- CITY /(f TEL. NOS , LAWN SPRINKLER SYSTEM � with comply with such provisions or this permit shall be STATE .UC. deemed revoked. WATER HEATER LICENSE NO.. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. o PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �� y (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER O and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL d ../�y DATE VALIDATBOIU. 0 License Number Lic. Class ! 0' U. ff� _ FINAL ContractoilL�/�-�� ate �� BY ❑ I am exempt under Sec. B.BP.C. for this reason Plan.checkfee Date: PLUMBING PERMIT ISSUING FEE$ �. Signoture TOTAL FEE �Q Plan check applicant SINGLE FAMILY HOMEOWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address Professions Code): City Tel. No. M_'H ❑ I, as owner of the property, will do the work and the e T,; ==E =30 structure is not intended or offered for sale (Section `: NL_ 7044, Business and Professions Code). "_ - is�•it 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 ab e- ntioned property f Rion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signal a of Permittee Date