HomeMy Public PortalAbout5233 FARAGO AVE_Plumbing__ DECLARATI
WORKER'S COMPENSATION
certificate
of consent to 76A6126DPW9/69 APPLICATION FOR PLUMBING PERMIT
76A667A
I hereby affirm that I have a certificate of consent [o self insure,
or a certificate of Worker's Comperration Insurance, or a certified
copy thereof(Sec:3800 dab. C.)
Policy N
��G1 KA / ��� COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
.
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �✓ 1 //C� A l—�
Certified copy is filed with the county bu' 'ng' pecti ADDRESS
departm NUMBER FIXTURE OR ITEM @ FEE
Date —/ LOCALITY
ry Applicant WATER CLOSET l[J� NEAREST _
��L.(, �c.►�
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION IN URANCE (� ASSESSOR
(This section need not be completed if the work involved by the SHOWER I � MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) LAVATORY 4 OWNER ��/�is/D�.�
3 /�E� C�
I certify that in the performance of the work for which this permit w...i
is issued, I shall not employ any person in any manner so as to SINKAIL
i L� S j ADDRESS �5� ���
become subject to the Workers' Compensation Laws.
DISWASHER S� CITY TEL.NO.
Date Applicant CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT: If, after making this Certificate of �G.
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM (�v
LICENSED CONTRACTORS DECLARATION / CITYI �. f�1C TEL.NO`�",S 3
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER 'T^ a
LIC.
(commencing with Section 7000) of Division 3 of the Business and n l STATE / tt� /y 0
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS `S _s5LICENSE NO. p'J CLASS (i 3
OUTLETS OVER DISTRICT NO. gR0 ESSED BY IZ
5 PER SYSTEM
O
7
License Number ` A Lia Class �� � v - �
J
DINAL
ATE /` VA DATION LU
Contractor__z _zwotc Dat ,, 0-
El -
I am exempt under Sec. FINAL ZBY
BAP.C.for this reason
Date:
Plan check fee ,
_
Signature PLUMBING PERMIT ISSUING FEE$ 2 �S
❑ TOTAL FEE Z5 5 5
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law F
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 algye2'to comply with all County ordinances
and State laws reg ting Plumbi , and hereby authorize
representat' of, s Count toe er upon the above-mentioned
roper n ion pur s
SEE REVERSE FOR EXPLANATORY LANGUAGE
C
Si ature of Permittee U Date
ION
DECLARAT
WORKER'S I have
a certificate
of consent to 76A666DPW9/89 APPLICATION FOR PLUMBING PERMIT
76A667A
I hereby affirm that I have a certificate of consent [o self insure,
or a certificate of Worker's Compepsation 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
Certifiedreopy is hereby furnished.
r-1FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY L
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. _
COMPENSATION INSURANCE ASSESSOR G �
(This section need not be completed if the work involved by the
SHOWER MAP BOOK �/� PAGQ�5�J PARCEL&!V q.
permit is for one hundred dollars($100)or less.) OWNER
1 certify that in the performance of the work for which this permit LAVATORY
is issued, I shall not employ any person in any manner so as toSINK MAIL
or
become subject to the Workers' Compensation Laws. ADDRESS
�. DISWASHER CITY TEL.NO.
Date. � Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after mCONTRACTORaking this Certificate of r
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS 12,
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO.
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER A
(commencing with Section 7000) of Division 3 of the Business and TATE GAS SYSTEM OUTLETS LICENSE NO. L CLASS 0
Professions Code,and my license is in full force and effect.
OUTLETS OVER DISTRICT Nd PROCESSED BY II
5 PER SYSTEM Q Q
License Number Lic.Class�— o V
FINAL
DATE VALIDATION
Contractor Data 3-/4 ^ rn
❑ I am exempt under Sec. BY AL
BAP.C.for this reason if J -630-17
30i1 *`i s 6
1. Plan check fee
ate: I ITEMS
9 PLUMBING PERMIT ISSUING FEE$ T i�Fit_
Signature
TOTAL FEE
� CA
Plan check applicant !
SINGLE FAMILY CHAN-GE c i IU
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 ; 'I a c±
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