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Home My Public Portal About5121 FARAGO AVE_Plumbing__ WORKER'S COMPENSATION certificate of consent to 76A666DPW9189 APPLICATION FOR PLUMBING PERMIT 76A667A I hereby afTirffi that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(S c. 800 ab. C.) ' A��,�COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS t DEPT. OF PUBLIC WORKS DIV. Policy No ompa Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING , Certified copy is filed with the county building i ADDRESS-,/of, cp j department NUMBER FIXTURE OR ITEM p FEE LOCALITY "— Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROMWR S' BATH TUB l� O CROSS ST. COMPENSATION INSURAN / ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) j OWNER --C` LAVATORY �v !!! ��r I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to SINK / ADDRESS lrG� MAIL become subject to the Workers' Compensation Laws. ^ DISWASHER CITY Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRES7 4W /.) provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM (/ LICENSED CONTRACTORS DECLARATION CITY L.N d I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER / As, STA E(commencing with Section 7000) of Division 3 of the Business and LICENSE NO. CLASS 0 Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS U OUTLETS OVER DISTRICT NO. PROCESSED BY 5 PER SYSTEM Q License Number " L. Class4mew FINAL a�lx / /J /�/� �/^ �l O DATE (� "/ VALIDATION CL Contractor�/ /`�/ ///�/ to rn ❑ I am exempt under Sec. BY FINAL _ B.&P.C.for this reason Plan check fee Dat . PLUMBING PERMIT ISSUING FEE$ OZ Signatur ❑ TOTAL FEE 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 G „ ••_,,,, 3•_,�.,,,�: � Code): Y ❑ City Tel. No. .;N ,y."• ,_s_., _i! I,as owner of the property,will do the work and the structure _ is not intended or offered for sale (Section 7044, Business , ;`,`•'• a__ and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the -. i.'`- '-'•j'-•- performance of the work for which this permit is issued (Sec. 3097, F,n•, 'y_cr,:;, 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 ofst n to enter upon the above-mentioned property fo 'Pouction purpose SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per ttee 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. EJ Certified APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �. Certified copy is filed with the county building inspection ADDRESS 51a J department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Tt CC� Date Applicant WATER CLOSET NEAREST BATH TUB CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. VLA 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($100)or less.) LAVATORY OWNER I certify that in the performance of the work for which this permit MAIL is issued, I shall not employ any person in any manner so as to SINK ADDRESS J S J r Y become subject to the Workers' Compensation Laws. DISWASHER CITY w` Ql TEL.N 71L� cry f-7 ,6 Date Applicant CLOTHES WASHER VEL CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of .(� Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS f,�G 3 C`; provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM 192. �j fl `tel LICENSED CONTRACTORS DECLARATION CITY U ✓ TEL.N 7` �y6��1 7� I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER CC11 D G (commencing with Section 7000) of Division 3 of the Business and STATE LIC. O Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS U OUTLETS OVER DISTRICT NO. FbOCEWEDBY Cc O 5 PER SYSTEM J I_ �` License Number Lic.Class �*J [. U DATE V/3FINALItL`tII).ATION 7 e !s LU Contractor Date T T rM1, U) r_1 I am exempt under Sec. BY AL 5R �_ TOTAL -_� a ® �3� BAP.C.for this reasoni': `:: 57 a 11 Plan check fee Date: IA•;( F Signature PLUMBING PERMIT ISSUING FEE$ 6 y�j ri tN�_ ❑ TOTAL FEE I SINGLE FAMILY Q - Plan check applicant ` 1'! !„!;—i I !1 HOME OWNER-BUILDER DECLARATION Name 0950 1 AN 11 e 17_*: 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address . 53 C.1114hrymal Y Code): El 1, .1—b 4i, Tel.N (�?Z 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 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 pr erty for inspection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE 1\ Signa re of Permittee ate