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Home My Public Portal About5109 FARAGO AVE_Plumbing__ 1m that I haveCOMPENSATION ate of consent to 76A666DPW9/69 APPLICATION FOR PLUMBING PERMIT 76A667A I hereby affirm that I have a certificate of consent to self insure, 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. BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS SLS AR 0 Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET NEAREST G,-�h� Ave, CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. BATH TUB COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) LAVATORY OWNER r heom 5 140a 40a I certify that in the performance of the work for which this permit MAIL p /A�� is issued, I shall not employ any person in any manner so as to SINK ADDRESS/2f-4Qj^�gy•� (j✓OVB !i�'� become subject to the Workers' Compensation Laws. DISWASHER CITY CB .1 j i TEL.Nit; Date Applicant CLOTHES WASHER �7 NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR%q ACTOR Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR A� provisions of the Labor Code, you must forthwith comply with such ADDRESS/25- �r,4vr e �7yv✓e- rfve provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY�,,�/J PasAe1e�/� TEL.NO. . I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER „6J►� 0 (commencing with Section 7000) of Division 3 of the Business and STATE � / LIC. 0 Professions Cade, and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. / CLASS /U OUTLETS OVER DISTRICT �� PROCESSED BY Cc 5 PER SYSTEM License Number Lic.Class FINAL DATE ` VAI,IQAIION Contractor Date ��.i ° 'a ❑ - ,:._+. � t-� I am exempt under Sec. BY FINAL i� y.j e T�• k, BAP.C.for this reason ITE 8I•: Plan check fee , Date: TOTAL i FfL 4 1 ST. PLUMBING PERMIT ISSUING FEE$ Signature � 0 i:HECr. TOTAL FEE CHNANGEp SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name -rhom,&S 14,0 Lir 4 I hereby affirm that I am exempt from the Contractor's License Law A . [I lii!i^ i i}i i r , for the following reason (Section 7031.5, Business and Professions Address t tr Code): yi / Tel. No.ZI,3 jl��/4 ,on_ i�7"i5 f Ad,1 i i i city❑ �h PdS6f0 Nc 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 representat' es of this County to enter upon the above-mentioned property fo inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �r Signature of Per tee Date WORKER'S COMPENSATION DECLARATION 6 DPW 9/89 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(SeMAZparry Lab. Policy No. a COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. � �. ' ❑ Certified copy is hereby furnished. 61 FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING }j ADDRESS .— �( Certified copy is filed with the county building pection ep rtment. NUMBER FIXTURE OR ITEM @ FEE LOCALITY / t Date / Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB / CROSS ST. f COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) LAVATORY OWNER -- I certify that in the performance of the work for which this permit � is issued, I shall not employ.any person in any manner so as toMAIL SINK , ADDRESS become subject to the Workers' Compensation Laws. / DISWASHER 41. CITY 66D _ Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of 1-!51A-,;2 Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM U `/ LICENSED CONTRACTORS DECLARATION CITY �f TEL.N a I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER "`✓✓✓ (commencing with Section 7000) of Division 3 of the Business and / n LICENSE NO.STATE �/q� CLASS — O Professions Code,and my license is in full force and effect. ( GAS SYSTEM UTLETS / V OUTLETS OVER /'j DISTRICT NO. PROCESSED BY � r— 5 PER SYSTEM / /V License Number Lic.Class FINAL 0 LLJ DATE (`O—(-q 3 VALIDATION Contractor EJ FINAL I am exempt under Sec. / � BY B.&P.C.for this reason Plan check fee PLUMBING PERMIT ISSUING FEE$ ; Signature - TOTAL FEE El 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 Professions Address Code): - ❑ I,as owner of the property,will do the work and the structure City Tel. No. 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 a9w9to comply with all County ordinances and St�fpspsecrtiion rpu�rFes,' umbing, and hereby authorize represeenter upon the above-mentioned property SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Pyr ee Date