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Home My Public Portal About5115 FARAGO AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 6DPW 9/69 76A667A APPLICATION FOR PLUMBING PERMIT ` 76A66 Cher eby 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. Ompany El Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county buildin in ion ADDRESS f t epartment. l NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date pplicant OL WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROG WORKCROSS ST.ERS' BATH TUB )/� COMPENSATION INSURANCE 2 /✓ ASSESSOR (This section need not be completed if the wor involved by the SHOWER MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) OWNER'--- 64S` I certify that in the performance of the work for which this permit LAVATORY is issued, I shall not employ any person in any manner so as toSINK MAIL become subject to the Workers' Compensation Laws. ADDRESS ` DISWASHER CITY� AY- - �7 Date Applicant CLOTHES WASHER / �j.� NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR ! � Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTORL— provisions of the Labor Code, you must forthwith comply with such ADDRES / provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM v' LICENSED CONTRACTORS DECLARATION CITYTEL.N� >_ WATER HEATER I hereby affirm that I am licensed under provisions of Chapter 9 • 0. (commencing with Section 7000) of Division 3 of the Business and STATE LIC. 0 Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. % CLASS — OUTLETS OVER DISTRICT NO. PROCESSED BY cc 5 PER SYSTEMy License Number ® ` Lic.Class a� i/� '/ O r V FINAL —7 DATE p .(� VALIDATION LU Contractor t/v to < - ❑ FINAL '`"` - . I am exempt under Sec. By B.&P.C.for this reason JI r, Plan check fee , Date. PLUMBING PERMIT ISSUING FEE$ 'i '' - '" Signature z y° ❑ / TOTAL FEEDo 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 ;'+;`a' 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 s o ter upon the above-mentioned property for in n p es. — SEE REVERSE FOR EXPLANATORY LANGUAGE Sign tura of Permittee Date ION WOthat I have a certificate of consent to 76A666DPW9/89 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. �/ C, FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ADDRESS 'l r 1✓ ❑ Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY e� Date Applicant WATER CLOSET tL NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. remit tL12— 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($100)or less.) LAVATORY d OWNEFq X I certify that in the performance of the work for which this permit VI is issued, I shall not employ any person in any manner so as toSINK MAIL become subject to the Workers'Compensation Laws. ADDRESS ' y DISWASHER CITY .Y TEL.N .n _n Date Applicant CLOTHES WASHER f7 NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOam Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS, r, provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM �!� LICENSED CONTRACTORS DECLARATION CITY TEL. O. } I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER LQ, (commencing with Section 7000) of Division 3 of the Business and STATE LIC. Professions Code, and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. W14 CLASS � V OUTLETS OVER DISTRICT NO. PROCESSED BY cc 5 PER SYSTEM License Number Lic.Class FINAL DATE /� � 006ATION -- ILI V � Contractor Date / .303 it[° cl) EJ `i': FINAL ZI am exempt under Sec. By B.&P.C.for this reason •�� Plan check fee , TOTAL 41 °° 8=� Date: � Signature PLUMBING PERMIT ISSUING FEE$ k�: {_-IE!_•Y; r j°'-`�t ❑ TOTAL FEE �J/ CHANGE Plan check applicant SINGLE FAMILY i' A '`+ HOME OWNER-BUILDER DECLARATION Name ��=�- =� -• I hereby affirm that I am exempt from the Contractor's License Law �y °s for the following reason (Section 7031.5, Business and Professions Address •� 094,21 1 Art 11::• Code): m ?Z 2 `{tea — �J I, as owner of the property,will do the work and the structure City Tel. o.�L� A L 11 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 Pol- and 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 operty for injection purrp"os-es. J / SEE REVERSE FOR EXPLANATORY LANGUAGE 00w,_(- Igna re of Permittee It ^Date