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HomeMy Public PortalAbout5020 FIESTA AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION PPLIC A TION FOR PLUMBING 1 1 I BIND PERMIT I�hereb�o'.firm that.1 have a certificate of consent to self 76A667A /"1 /`1 LV�Yit R�Y� insure, dr d certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certifi d copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No `'�CFnpany�r Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING "�©sy Certified copy is filed with th county building ' spec- ADDRESS ✓ G tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date s Applico d�� WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION F M WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by the permit is for one hundred dollars $100 or less. MAIL p ( ) ) LAVATORY ADDRESS I certify that in the performance of the work for which this � permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER / LLL 446 CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of I Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY L TEL. NO with comply with such provisions or this permit shall be STATE . �/ LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROC SE BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �l(/ (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER C!Q and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINf� DTE A �� LIDATION License Number Lic. Class B" FINA Of Contractor Date BY ❑ 1 am exempt under Sec. B.&P.C. for this reason Plan check fee Dare: t-- 22258 Signature PLUMBING PERMIT ISSUING FEE$ d J d ,0 0 3 a 5 ' TOTAL FEE Plan check applicant 0 0 0 0 3 Q 5 p SINGLE FAMILY O � � 3_8 5 HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions 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.). TEMPLE CITY Bl�iLGlNr DE��RT�IIEIV Lender's Name 5938 N. KAUFFMAN AVENUE Lender's That TEMPLE CITY, CALIFORNIA 91780 1 certify that I have read this application and state that the — (818) 2850488 ► above information is correct. I agree to comply with all County abo ces and State laws regulating Plumbing, and hereby ze representati s of this County to enter upon the mentioned perry for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �: --- Signat a of Permittee Date WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I °x;ereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers' Cpmpensation Insuran. 76A667A `- or a certified copy thereof (Sec. 3800 lab. C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnthe county building inspec- ' BUILDING r ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS �2 O I Certified copy is file ith tion department NUM ER FIXTURE OR ITEM @ FEE /J LOCALITY Date Applicant WATER CLOSET .�� /d NEAREST CER FICATE OF EXEMPTION FROM WORKERS' BATH TUB D CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by the permit is for one hundred dollars($100)or less.) LAVATORY MAIL ADDRESS I certify that in the performance of the work for t permit is issued, I shalt not employ any per y man r SINK O CITY TE so as to b�67e subject to the Worker ' nsatio DISHWASHER O CONTRACTOR Dat Applican CLOTHES WASHER ADD ►_l NOICE TO APPLI A T: If, a .r making this Certi ' of SWIMMING POOL RECEPTOR Exemption, you sh uld become subject to the Work Compensation provisions of the Labor Code, you mu orth- LAWN SPRINKLER SYSTEM CITY ( i TEL. Nb� with comply with such provisions or this p shall be STATE ��•^^ LIC. 22 deemed revoked. WATER HEATER LICENSE NO. C7 CLASS ` J LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ✓D f7 �� (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER C� and Professions Code,and m license is in full force and effect. 5 PER SYSTEM Y FINAL VALIDATION LLQ ,� � � License Number ' Lic. Class DATE ®;0, FINAL Contractor ate ` BY ❑ I am exempt under Sec. �v B.&P.C. for this reason Plan check fee v� e. PLUMBING PERMIT ISSUING FEE$ Signature � (a- TOTAL FEE 10 U Plan check applicant � SINGLE FA 1LY HOME OWNER-BUILDER LARATION Name a_ I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and , Professions Code): City Tel. No. �' s •'�-' ❑ I, as owner of the property, will do e work and the (?-ice structure is not intended or of ed for sale (Section ® rte•!e+`."..\:i'1 ,, ..i' ti3 7044, Business and Professi Code). _ CONSTRUCT] ENDING AGENCY I hereby affirm that th s a construction lending agency for the performance e work for which this-permit is issued (Sec. 3097, Ci .). - :-t- Lender' Name _•t ;{� C:,::.^, Lender's Address I certify that 1 have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws r ting Plumbing, and hereby authorize rep 1 ti of th' County to enter upon the above-mentio p ert pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sig re of Permitte� Date „ 20-0026 DPW 9/69 WORKER'S COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 76A667A I hereby affirm that I have a certificate of consent to self insure, or a certif(cve of Worker's Compensation Insurance, or a certified copy*,ier8of(Sec. 3800 Lab. CJ S J COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No. Company �C JL1�, Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING El Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY Date Applicant � WATER CLOSET aC� S_Z NEAREST N L,V-10CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST, l> COMPENSATION INSURANCE BATH TUB p�a �® ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK r 9 O PAGE ® PARCEL D f/k permit is for one hundred dollars($100)or less.) OWNER I certify that in the performance of the work for which this permit LAVATORY is issued, I shall not employ any person in any manner so as toSINK MAIL become subject to the Workers'Compensation Laws. ADDRESS DISWASHER CITY /.� G TEL.N �/ Date Applicant CLOTHES WASHER IsCS r NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR .� Exemption,you should become subject to the Workers' Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS 7 5 provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO Lao I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER@y M112 0 !r4 (commencing with Section 7000) of Division 3 of the Business and STATE LIC. /� Professions Code, and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. � CLASS —1S OUTLETS OVER DISTRICT NO. PRO SSED BY 5 PER SYSTEM h j% � License Number Lic.Class FINAL DATE 7 VALIDATION Contractor Dateco ❑ I am exempt under Sec. FINAL yj BAP.C.for this reason Plan check fee , Date: Signature PLUMBING PERMIT ISSUING FEE$ / ❑ TOTAL FEE SINGLE FAMILY Plan check applicant y' HOME OWNER-BUILDER DECLARATION Name �.:1 M 7 ir I hereby affirm that I am exempt from the Contractor's License Law w, j_ __ cz_f for the following reason (Section 7031.5, Business and Professions Address •:'_ Code): El 1, Tel.No. i i EN'S _ I,as owner of the property,will do the work and the structure i h ,�, � .� is not intended or offered for sale (Section 7044, Business €CIL =� g and Professions Code). , - _ - f CONSTRUCTION LENDING AGENCY - I hereby affirm that there is a construction lending agency for the t" ��t� performance of the work for which this permit is issued (Sec. 3097, Civ. C.) i i310 l 1-101 t t 1 111 Y • . 4s,`I Lender's Nam L.6.f 1 ° 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