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Home My Public Portal About5225 FARAGO AVE_Plumbing__ DECLARATI WORKER'S COMPENSATION ate of consent to 76A666DPW9/89 APPLICATION FOR PLUMBING PERMIT ll I hereby affirm that I have a certificate of consent to self insure, 76A667A or-a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec 800 Lab,xC,) �� l COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy N any ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING S1_ �G O ❑ ADDRESS Certified py is tiled with the county buil spectio part ent NUMBER FIXTURE OR ITEM r� FEE LOCALITY Date Applicant WATER CLOSET -3 NEAREST CROSS ST. CERTIFICATE OF EXEMPTION OM WORKERS' BATH TUB 2t O ASSESSOR 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($100)or less.) LAVATORY OWNER I certify that in the performance of the work for which,this permit is issued, I shall not employ any person in any manner so as toSINK ^ �� ADDRES MAIL �a become subject to the Workers'Compensation Laws. hj— / DISWASHER iJ"S CITY '7► TEL.NS �� Date Applicant CLOTHES WASHER ri CONTRACTORS/ NOTICE TO APPLICANT: If, after making this Certificate of 'V Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM /�/ y �/�'`� LICENSED CONTRACTORS DECLARATIONL _ CITY C/��! - TEL.N&7 7 WATER HEATER I hereby affirm that I am licensed under provisions of Chapter 9 � �� (commencing with Section 7000) of Division 3 of the Business andr- STATE .�— LIC. O Professions Code,and my license is in full force and effect. / GAS SYSTEM s OUTLETS ,CSS LICENSE N CLASS V OUTLETS OVER DISTRICT NO. RO SSED BY Q 5 PER S STEM License Numb e Lic.Class n !1 O FINAL W / G� CL DATE �2 (� VALIbATION Contracto w!`'�-'/ Date f) ❑ FINAL Z I am exempt under Sec. BY B.&P.C.for this reason Date: Plan check fee , Signature PLUMBING PERMIT ISSUING FEE$ ❑ TOTAL FEE SINGLE FAMILY 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): ❑ 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 - =-z, 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 �` r- - Lender's Address I certify that I have read this lication a ate that the above information is correct. I a e to compl ith all County ordinances -- and State laws reg ting m g, and hereby author' e _ representati f s Cou y to r upon he ab menti ned / propert ion pur es. CJI// SEE REVERSE FOR EXPLANATORY LANGUAGE Si ature of rermittee Date ION DECLARATI ' WORKER'S I have a certificate of consent to 76A666DPW9/89 APPLICATION FOR PLUMBING PERMIT 11 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.) Policy ,No. OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. ❑P �No. � Company Certified copy is hereby furnished. BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM pa FEE LOCALITY a 0, Date ApplicantWATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH.TUB CROSS ST. COMPENSATION INSURANCE MAP BOOK /� PAGE y PAR (This section need not be completed if the work involved by the SHOWER �/ �Qa permit is for one hundred dollars($100)or less.) LAVATORY OWNER �r, I certify that in the performance of the work for which this permit MAIL is issued, I shall not employ any person in any manner so as to SINK ADDRESS become subject to the Workers'Compensatf'n Laws. 13 f � DISWASHER CITY TEL.NO. Date/ad /Applicant , � CLOTHES WASHER NOTLI ANT: If, after making this Certificate of NTRACTOR Exemption,you should become subject to the Workers' Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM G LICENSED CONTRACTORS DECLARATION CITY �1 TEL.N0��6��// Y I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER / (commencing with Section 7000) of Division 3 of the Business and STATE C� LIC. Professions Code, and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO.� /� CLASS / (� OUTLETS OVER DISTRICT NO. PROCESSED BY License Number Ya 7? Lic.Class 5 PER SYSTEM �� Q FINAL c W Contractor Date DATE U Z VALIDATION.TION 0- � ir/D,� rx �ir�i�:t HkA.I o W ❑ I am exempt under Sec. BY FINAL - .,.,�.� r. 6 B.&P.C.for this reason ) rTEM'-� Plan check fee _ t I Signature Dam PLUMBING PERMIT ISSUING FEE$ s '� ® �—g ❑ TOTAL FEE 'tl_i f� °65 SINGLE FAMILY Plan check applicant CHANGL ,110 HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law i i for the following reason (Section 7031.5, Business and Professions Address 00130-000 1 ._1,=j1i,31 Code): El 1, Tel. No. €=f 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date