The URL can be used to link to this page

Home My Public Portal About5215 FARAGO AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION I hereby, affirm that I'haAPPLICATION FOR PLUMBING PERMIT 76A66v'e o certificate'of'consent to self in- � 76A667A 20-0026,DPW 4/87 sure,or a certificate of Workers"Com ensation Insura or a CE 817(REV. 8/86) certified copy thereof (Sec. 3800, La •:) 1 ;.s Policy No.�Compa kffi2 IYl l�h COUNTY OF LOS ANGELES DEPT:'°OF PUBLIC WORI<St i Certified copy is hereby furnis ed. • FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ._ /�_ p� Certified copy is filed with the county building inspection ADDRESS /l( department. l NUMBER FIXTURE OR ITEM @ FEE 4 V WATER CLOSET(TOILET) /� LOCALITY% / Date r` 6 ' Applicant �50. NEAREST T CERTIFICATE OF EXEMPTION FROM WORKERS' 'BATH TUB CROSS S7: ti / "'.,'�f} COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) Z LAVATORY ADDRESS ( � �i 1�� I certify that in the performance of the work for which this perSQP- INKissued, I shall not employ any person in any manner so SINK CITY TEL. NO. as to become subject to the Workers' Compensation Laws. ` DISHWASHER / C CONTRrETED Date Applicant CLOTHES WASHER 7 5U. ADDRE NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- ') ��y� TEL. NO. cation provisions of the Labor Code, you must forthwith comp- TY d' / r" J/ a LAWN SPRINKLER SYSTEM i ly with such provisions or this permit shall be deemed revok- STATE q LIC. /p- ed. / WATER HEATER LICENSE NO. d �3 / CLASS LICENSED CONTRACTORS DECLARATION � DISTRICT NO., ROCESS BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS jS(� 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL V LID IOfd >_ fest. � 3�� l _ DATEq_,1J 0 License Numbe Lic. Class �� L Q( r1 FINAL V Con,6c'1&'\-P1L Q aC 1 `• Date I -�6 `�v BY 0 ❑ 1 om exempt under Sec. 6.8P.C. for this reason Plan check fee fA ate: I� { PLUMBING PERMIT ISSUING FEE$ S . - TOTAL FEE SI73 ou NGLE FA Y HOME WNER-BUILDER ECLAR TION Plan check applicant f: �E I.hereby affirm that am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and ACCT Professions Code): Address '307 1<5.elJ I, as owner of the property, will do the work and the City Tel. No. � structure is not intended or offered for sale(Section 7044, MS Business and Professions Code). TOTAL AL m 50 CONSTRUCTION LENDING AGENCY ► CHECK 12c,51; I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CHANGE (Sec. 3097, Civ. C.). Lender's Name 0001,11-0001 1/26/9LI Lender's Address 8.516 1 AIM 1G= 7 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 76A666 DPW 4/87 I hereby, affirm that I.have a certificate of consent to self in- 76A667A sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) certified copy thereof (Sec. 3860, Lab. C') ' Policy No. /Pq Companyr/1 IR- 1 LIA a(, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Q Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESS Sp (J NUMBER FIXTURE OR.ITEM department. @ FEE ft LOCALITY (- / r Date Applic WATER CLOSET(TOILET) 42 a NEAREST ` 3��f- .`ftp CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE O SHOWER OWNER fz (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars (;100)or less.). LAVATORY 0 �/ ADDRESS q1 (�s� I certify that in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so CITYAf - TEL. NO. as to become subject to the Workers' Compensation Laws. DISHWASHER 5 a � CONTRACTOR Date Applicant CLOTHES WASHER 7 ,50 ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CIT � TEL. NO.I/U sation provisions of the Lobor Code, you must forthwith comp- h LAWN SPRINKLER SYSTEM ;64 174 T ly with such provisions or this permit shall be deemed revok- V STATE , '10--3 ,1— LIC. ed. WATER HEATER LICENSE NO. /v--3 ,1 CLASS LICENSED CONTRACTORS DECLARATION 0 DISTRICT NO., CESSED Y I hereby affirm that I am licensed under.provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of'Division 3 of the Business OUTLETS OVER ✓ ID and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL riV LIDATION fect. DATE (- License Number62903 K-3 Lic. Class e _ �� V Contr c - Date t —d-6" i� BY AL 0 O 1 am exempt under Sec. B.&P.C. for this reason CL Plan check fee U) DaterF' ' 70 PLUMBING PERMIT ISSUING FEE$ 1.3 pool Si TOTAL FEE 50 SINGLE FA ILY HOME OWNER-BUILDER DECLARATION Plan check applicant c I hereby offirm'that I am exempt from the Contractor's License NameI• Law for the following reason (Section 7031:5, Business and ACCTAr Professions Code): Address ;-� 1.i.•. S 3307J1� 5 O•.II El 1, as owner of the property, will do'the work and the City Tel. No. 1 ITEMS structure is not intended or offered for sale(Section 7044, ��;T Business and Professions Code). 125 -50 CONSTRUCTION LENDING AGENCY pop. CHECK . 125s50 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CHANGE ■00 (Sec. 3097, Civ. C.). Lender's Name 000 —L-1001 1/76/4x] Lender's Address 13 1A1f41�7u 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date