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Home My Public Portal About5229 FARAGO AVE_Plumbing__ ION 20 WORKER'Shave a certificate of consent ON 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 ec..3800 Lekb. C. Q.� � � COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No ny ❑ Certified copy is hereby furnished.❑ BUILDING-� FOR APPLICANT TO FILL IN(PRINT OR TYPE) Certified opy is filed with the county build' 'inspection ADDRESS artm nt. v/ / NU ER FIXTURE OR ITEM Q FEE LOCALITY Date , Appli WATER CLOSET 4 ,S NEAREST — C CERTIFICATE OF EXEMPTI N FROM WORKERS' 10 BATH TUB , L O CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER n �C MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) LAVATORY /)�T 5S OWNER I certify that in the performance of the work for which this permit 4 v+� is issued, I shall not employ any person in any manner so as to SINK 1 4 �� MAIL �� -3 ADDRESS !r become subject to the Workers'Compensation Laws. DISWASHER SS CITY TEL.NO. Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY O4_,�2—TEL.NO.�°7 t✓ y- I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER 14 J (commencing with Section 7000 of Division 3 of the Business and STATE LIC. ...- Professions Code, and my license is in full force and effect. GAS SYSTEM OUTLETS Q cJ LICENSE NO. 7,J CLASS � 0 OUTLETS OVER `7- DISTRICT NO. P OCE SED BY cc 5 PER SYST M (h O License Numb d `J Lic.Clas(r� _ 10 �ell / 0 �J7 FINAL `�Z ✓� ( DATE VA ID 4A,ON LU _ y Contracto�"�,// Date / Cl) ❑ I am exempt under Sec. FINAL BY BAP.C.for this reason Date: Plan check fee Signature PLUMBING PERMIT ISSUING FEE$ Z14 `75 ❑ TOTAL FEE 57 c�5 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 _ and Professions Code). , _ T 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 thy.application and state that the above , information is correct.,L-Mgree to com with all County ordinances and State laws re, §.ulating PI ng, and hereby authorize represent this Count o enter upon the above-mentioned rop f pection urp SEE REVERSE FOR EXPLANATORY LANGUAGE Si nature of Permittee Date WORKER'S COMPENSATION DECLARATION 6DPW 9/89 APPLICATION FOR PLUMBING PERMIT 76A66 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.3800 Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. i 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 l department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSETof NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. t COMPENSATION INSURANCE ASSSSOR MAPBOOK �►�/Cit PAGp*:9tf' PA� (This section need not be completed if the work involved by the SHOWER permit is for one hundred dollars($100)or less.) OWNER �� G LAVATORY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as toSINK MAIL become subject to the Workers' Compensation Laws. ADDRESS j I �� anJ��`�i�� DISWASHER CITY TEL.NO. Date-NA � CLOTHES WASHER �� NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR �rJ Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NOS/t/l V///L �- I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER t. (commencing with Section 7000) of Division 3 of the Business and SC NSE NO. f CLASS U Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS OUTLETS OVER DISTRICT NO. PROCESSED BY 5 PER SYSTEM License Number Lic.Class FINAL DATE 2� VALIDATION LLI ' CL Contractor Date Cl) ❑ FINAL I am exempt under Sec. BY B.&P.C.for this reason ACC, Dat • Plan check fee , 33 1 I7 fi Signature 7 PLUMBING PERMIT ISSUING FEE$ S 1 ��Eh- ❑ TOTAL FEE �) 1,0 t I AL 40 ffi 65 Plan check applicant d:`; i =c SINGLE FAMILY HO �•Uo6 HOME OWNER-BUILDER DECLARATION Name €S pp Ilf'�°J III.I 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. r•^;_: :, ., ,., I, as owner of the property,will do the work and the structure 0010 I L,I0;0b 3f 1 j,`'k• is not intended or offered for sale (Section 7044, Business _.�i 1 7 1 AM 10:51 and Professions Code). ► 1 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