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Home My Public Portal About5119 FARAGO AVE_Plumbing__ J WORKER'S COMPENSATION DECLARATION 720-0026 6A667APW9/89 � APPLICATION FOR PLUMBING PERMIT 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. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ❑ Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY G( Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. v(t, 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.) OWNER¢, I certify that in the performance of the work for which this permit LAVATORY Jul is issued, I shall not employ an person in an manner so as to MAIL x P Y Y P Y SINK ADDRESS C ( �C become subject to the Workers'Compensation Laws. DISWASHER CITY TEL.N .2 Uq SCI-74 Applicant CLOTHES WASHER CONTRACTOR [�- NOTICE TO APPLICANT: If, after making this Certificate of 6 W nQ Exemption,you should become subject to the Workers' Compensation SWIMMING POOL RECEPTOR ADDRESS provisions of the Labor Code, you must forthwith comply with such W-2, cliff wrk provisions or this permit shall be deemed revoked. ! LAWN SPRINKLER SYSTEM CITY 622 TEL.N LICENSED CONTRACTORS DECLARATION 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 STATE LIC. GAS SYSTEM OUTLETS LICENSE NO. CLASS Professions Code,and my license is in full force and effect. OUTLETS OVER DISTRI T (Y �� PROCESSED BY 5 PER SYSTEM �'"�� License Number Lic.Class c� FINALVx1 1DATION '� LU LU DATE iq •`/� $i•i +��•� a. Contractor Date �✓ _! T ❑ I am exempt under Sec. FINAL LS = B.&P.C.for this reason s-THL 4 1. m 15 Plan check fee r``l;r � t t o�•_ HECK Date: 1. Signature PLUMBING PERMIT ISSUING FEE$ a�c_ Vo , t:hsyNGE ❑ TOTAL FEE SINGLE FAMILY Plan check applicant �I�1I_! 711'26/9 r t�—V:�a.s :•_ HOME OWNER-BUILDER DECLARATION Name cJ Ct e a h l�lll )1Q47 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address I•-7S 3 r itYGl h r Code): *ffb ElCity u y Tel.N .7/f X6f 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 enter upon the above-mentioned ropertyfo inspection pur ses. ,,/ 2 SEE REVERSE FOR EXPLANATORY LANGUAGE (i P _ ! J Sighfiture of Permittee Date .WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9/89 APPLICATION FOR PLUMBING PERMIT 76A667A I hereby affirm that t have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(S c. B00 b. C') An�OUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. ElNo./"� mpan `LJ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ! � Certified copy is filed with the county buildin in a ADDRESS d artment l NUMBER FIXTURE OR ITEM Q FEE LOCALITY Data eZ&plicant 0;1, WATER CLOSET NEAREST �- sem^ CERTIFICATE OF EXEMP ION FROM WO BATH TUB CROSS ST. COMPENSATION INSURANCE ASSESSOR MAP BOOK{DfJ PAGE PARCEL (This section need not be completed if the work involved by the SHOWER p /7 permit is for one hundred dollars($100)or less.) LAVATORY ��yy, OWNER % l 7� I certify that in the performance of the work for which this permit d/. L V MAIL is issued, I shall not employ any person in any manner so as to SINK ADDRESS r �� become subject to the Workers' Compensation Laws. DISWASHER CITY f �J �r ///J�L�/ Date Applicant CLOTHES WASHER `'vU NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM �7 LICENSED CONTRACTORS DECLARATION CITY >_ I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER 0 (commencing with Section 7000) of Division 3 of the Business and STATE LIC. Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS � LICENSE NO. �� CLASS �'- OUTLETS OVER DISTRICT NO. PROCESSED BY License Number Y v Lia Class `— 5 PER SYSTEM 1 ® 0 0 0 �,/ _679 FINAL DATE �, C� VALIDATION LU Contractor !/JL Date U) ❑ ow FINAL _„. ..___.....".F I am exempt under Sec. BY �T B.&P.C.for this reason Plan check fee , 3-1 4".. Dai� Signature PLUMBING PERMIT ISSUING FEE$ Y• t yr �i'f ❑ TOTAL FEE A N`E SING Plan check applicant ILY HOME OWNER-BUILDER DECLARATION Name :-t;;z;•, +:;•• 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): ❑ 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 this C n sto enter upon the above-mentioned property for inspeall. SEE REVERSE FOR EXPLANATORY LANGUAGE Ig dfure of.P' Date