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Home My Public Portal About5117 FARAGO AVE_Plumbing__ DECLARAT • 11 WORKER'S COMPENSATION certificate of consent to 76A666DPW9189 APPLICATION FOR PLUMBING PERMIT ll 76A667A I hereby affirm tHat I have a certificate of consent to self insure, or h certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec 3800 Lab ) _ e COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No. mpany ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDINGf Certified copy is filed with the county building ins ADDRESS /t" r d art nt. r- NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date plicant WATER CLOSET NEAREST ,v CROSSST.sj�� CERTIFICATE OF EXEMPTION FROM W03YrERS`' BATH TUB ASSESSOR AA COMPENSATION INSURANCE (This section need not be completed if the work involved by the SHOWER MAP BOOK / PAGE PARCEL permit is for one hundred dollars($100)or less.) LAVATORY OWNER ✓ /�.` s� I certify that in the performance of the work for which this permit !T is issued, I shall not employ any person in any manner so as to SINK MAIL ��( become subject to the Workers' Compensation Laws. ADDRESS,( [ DISWASHER CITY r �� Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with suchSte/ provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY , EL hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER CL (commencing with Section 7000) of Division 3 of the Business and STATE LIC. O Professions Code, and my license is in full force and effect. GAS SYSTEM �_ OUTLETS LICENSE NO. ` CLASS OUTLETS OVER DISTRICT NO. PROCESSED BY 0 5 PER SYSTEM p License Number • L LIC.Classcs)�T f— / FINAL IU Contractor l' 7 DATE .t� VALIDATION a ate r ILU) ElFINALS- I am exempt under Sec. / gY _ B.&P.C.for this reason r Plan check fee ate: PLUMBING PERMIT ISSUING FEE$ Signature _3_3 ❑ TOTAL FEE y,L, "; T. SINGLE Y Plan check applicant 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): F1 1, 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). pop- CONSTRUCTION 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 PI mbing, and hereby authorize representatives of tws ter upon the above-mentioned property for ins e p oses. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permi a Date ION 2G-002 WORKER'S I have a certificate of consent to 76A668DPW9/89 APPLICATION FOR PLUMBING PERMIT 76A667A I herelty�affi�m 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.) Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. ❑ Certified copy is hereby furnished.❑ BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE)Certified copy is filed with the county building inspection ADDRESS 6-117 department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY ,,/ C Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. /V q 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($100)or less.) LAVATORY OWNER a r! c� I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as toSINK MAIL r_� become subject to the Workers' Compensation Laws. ADDRESS 1153 C(( 10-0!'f C jI' n r DISWASHER CITY ga` TEL.*71V AI 7Z Date Applicant CLOTHES WASHER l NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR ® VJ v\_R j Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS c3 rU�1 Li provisions or this permit shall be deemed revoked. r ' LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL. p� I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER m ! Lq2OP-Z {7 (commencing with Section 7000) of Division 3 of the Business and STATE LIC. q� o Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS ! J OUTLETS OVER DISTRICT NO. PROCESSED BY Er 5 PER SYSTEM License Number Lic.Class FINAL ��. LLJ DATE (7_j VA&ATION n Contractor Date 1 1 t Gt tl (n ❑ I am exempt under Sec. FINAL TOTAL LSL 41 35 B.&P.C.for this reason _ 101. "HECK iti.r.1" Plan check fee Date: CHANGE n i?I Signature PLUMBING PERMIT ISSUING FEE$ �G Q ❑ TOTAL FEE Plan check applicant 09 0 0—'!1 31 I 1 -7,r ,74 SINGLE FAMILY t r�i HOME OWNER-BUILDER DECLARATION Name 1 I�G`fr AN i>>3 1 hereby affirm that I am exempt from the Contractor's License Law Ck for the following reason (Section 7031.5, Business and Professions Address r Code): ❑ City aWW651,,1 ` Tel. 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 this County to nter upon the above-mentioned pr perty for ins ection purposes. %, SEE REVERSE FOR EXPLANATORY LANGUAGE cti .3 SIgnatiRe of Permittee Date