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Home My Public Portal About9129 EMPEROR AVE_Plumbing__ t WORKER'S COMPENSATION DECLARATION 6DPW9/69 APPLICATION FOR PLUMBING PERMIT 76A66 I hereby affirm that I have a certificate of consent to self insure, 76A667A or a certificate of Worker's Compensation Insurance, or a certified copy thereof(sec.3800 Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESS a v►r .Q I� department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. ,!�_ COMPENSATION INSURANCE ASSESSOR f (This section need not be completed if the work involved by the SHOWER MAP BOOK D� PAGE��'�_ PARCEL permit is for one hundred dollars($100)or less.) LAVATORY OWNE I certify that in the performance of the work for which this permit TO,-, j;L is issued, I shall not employ any person in any manner so as toMAIL SINKZy become subject to the Workers'Compensation Laws. ADDRESS DISWASHER CITY ` TEL.NO. \ �s 7 D to �naA an CLOTHES WASHER N TICE TO AP ICANT: If, after making this Certificate of CONTRACTOR Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER 0. (commencingwith Section 7000) of Division 3 of the Business and STATE NO. CLASS O Professions Code,and my license is in full force and effect. l GAS SYSTEM / OUTLETS �� V OUTLETS OVER DISTRICT NO. PROCESSED BY O 5 PER SYSTEM !J License Number Lic.Class V FINAL VALIDATION LL DATE �,,•r_[� (L Contractor Date JJ I (n ❑ I am exempt under Sec. FFY AL Z B.&P.C.for this reason H% .r Date: Plan check fee , 3 117 40.651 PLUMBING PERMIT ISSUING FEE$ lO5 Signature 1 IT E MS TOTAL FEE �. TOTAL 40 - 65 SINGLE FAMILY Plan check applicant CHECK 40.65 HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law CHANGE ,CI for the following reason (Section 7031.5, Business and Professions Address Code): NA City Tel. No. I,as owner of the property,will do the work and the structure �i�i�1 i-1 II�0�, 5/17/93? is not intended or offered for sale (Section 7044, Business i i 1 N �/ I� and Professions Code). , 1. 1 ? f f 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 Lor inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE `r Si ture of Permit ee Dat WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT ' `r "' 20-0026 DPW 4/87 I hereby, of;irm that I have a certificate of con;entA6 self in,, 76A667A sure, 6r a certificate of Workers'compensation Insurance,or a CE 817 (REV. 8/86) certified copy thereof (Sec. 3800, Lab. C. Policy No: Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Certified copy is hereby furnished. „ ' FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING CfI A� F-] Certifiedcopy is filed with the county building inspection ADDRESS L department. NUMBER FIXTURE.OR ITEM @ FEE LOCALITY J �' Date Applicant WATER CLOSET(TOILET) NEAREST l CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 0 CROSS ST. COMPENSATION INSURANCE SHOWER. OWNER U (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100) or less.) LAVATORYADDRESS Z �/� '� V I certify that in the performance of the work for which this per- SINK Oe mit is issued, I shall not employ any person in any manner so CITY TEL. NO. as to become subject to the Workers'Compen tion Laws. DISHWASHER -?,1 / % ONTRACTOR ' Date 2-- v Applicant CLOTHES WASHER A 'V A' ADDRESS 9� � NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR (((NVVV emption, you should become subject to the Workers'-Compen- sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM d TEL. NO. ' ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRO ED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ty (1 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER /V7 and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION fect. DATE t. Q� License Number 1 y " Lic..Class _�� D 0 V - C1/r lJj2 FINAL Contractor CV1�dA �l� Date �r BY p F- I am exempt under Sec. V LU B.&P.C. for this reason 9Ltry Plan check fee � PLUMBING PERMIT ISSUING FEE$ ® Signature 101111'. TOTAL FEE 1J''� SIN LE FAMILY HOME WNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and Professions Code): - Address , ACCT.'T I, as owner of the property, will do the work and the y 3`Fj?€ 9 .50 cl Cit Tel. No. .structure is not intended or offered for sale(Section 7044, ITEMS Business and Professions Code). ► "\ TOTAL 50 CONSTRUCTION LENDING AGENCY c- c I hereby affirm that there is a construction lending agency for CHECK •.fl .50 the performance of the work for which this permit is issued CHANGE (Sec: 3097, Civ. C.). Lender's Name 0000—OW1 `/iv/?'t Lender's Address 919,E 1 Ate 9:43 I certify that I have read this application and state that the above information is correct.,I agree to comply with all County t ordinances and State laws regulating Plumbing, and hereby aut"re' atives of this County to enter upon the obrop rty for inspection purposes. " ZZ SEE REVERSE FOR EXPLANATORY LANGUAGE Sign[ ign ture of Permittee Date