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Home My Public Portal About9409 GARIBALDI AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self •76A667A ' Insure, or a certificate of Workers' Compensaflon Insurance, CE817(it& 10/81) or a certified copy thereof (Set. 3800, Lab, C.) CO JNTY OF LOS ANGELES BUILDING AND SAFETY PoIIcy No. Company ❑ Certified copy Is hereby fumished. BUUDING El • FOR APPLK:�NT TO FILL IN(PRINT OR TYPE) O �Q / Certified copy Is filed with the county building Irnpoc- ADDRESS 6!0e tion department. NUMBER RX URE OR ITEM O FEE LOCALfFY f Date Appligont WATER CLOSET NEAREST FIC CERTIATE OF EXEMPTION FROM WORKERS' BATHTUB r� CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This section need not be complofod If the vrork Involved by the pormlit Is for one hundred dollars ($1010)or lees.) LAVATORY ADDDDIRLSS I certify that In the performance of the work for which this permit Is Issued, I shall not employ any pefson In any manner • SINK CITY TEL.NO..:2 /5' so as to become subject to the Workers Compensation Laws. DISHWASHER CONTRACTOR Date A npllcanf CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Cwttfltate of ADDRESS Exemption, yqu should become subject to the Worker' SWVA44JNG POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY 18 � with comply with such provisions or this permit shall be STATE LIG deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION r DISTRICT BY I hereby affirm thaf 1 pm IIcer4ed under provI&Ians of Chapter 9 GASSYSTEM OUTLETS t (commenting with Section 7000) of Division 3 of the Busmen OUTLETS OVER and Professions Code,and my license is In full force and effect. s PER SYSTEM FINAL f r / VALIDATION DATE + ! License Number LIc. Class FINAL Contractor Date BY 1 am exempt under Sec. B.BP.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check opplltant SINGLE FAMILY HOW OWNER43UILDER DECLARATION Name , I hereby affirm that I am exempt from the Contractor's License Address for the following reason (Section 7031.5, Business and Profess Iona Code): City. Tel. No. A9 0 8 5 A I, as owner of the property, will do the work and the structure Is not Intended or offered for sale (Section , o o,o o o 5 70.01, Business and Professions Cod l CONSTRUCTIO -LENDING 2'o.o 3 4.•5 0 I hereby affirm that there Is onstruct n lendlnq agency for o•o -Z �,5 0 6 the performance of the work r h this permit Is Issued (Sec. 3097, Civ. C. Q 1, 1 4—8'7z Lenders Name Lender's�¢dres I certify that I have read s appllcatlon nd state that the , above Informatlgn 1s c . I agree to cam ly with all County ordinances and,State I regulgtln0 Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned property Inspection pu SEE REVERSE'FOR EXPLANAT40RY LANGUAGE Signature of Permittee Dato WORKERS'COMPENSATION DECLARATgN APPLICATION FOR PLUMBING PERMIT I hereby afflrm that I have a certificate of'consent to self 7y467A Insure, or a certlficatb of Worbers' Compensation Insurance, CL 817(REV. 10181) or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY t Policy No. Company ❑ Certlfled copy Is hereby fumished. h El tion APPIJG4MT0 FILL IN(PRINT OR TYPE) BU 10 NG V Certified came Is filed with the county building Inspec- ADDRESS NU&42a FIXTURE OR ITEM FEE v tion departmeat. LQCALTTY f� - Date Appllgant WAS C105Et r REST CERTIFICATE OF EXEMPTION FROM WORKFAS' BATH TUB CROSS ST' COMPENSATION INSURANCES}per OWNER {J (This section need not be completed ff the work Irrvotwd by the permtt Is for arra hundred dollars (;100)or less.) LAVATORY DRESS I certify that In the performance of the work for which this permtt Is Issued, I shall not employ any person In any manner SINlc CITY TEL NO. so as to become subject to the Workers Compensation Lqws, DISHWASHER CONTRACTOR Date A,plicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workors CITY Compensation provisions of the Labor Code, you must forth- LAWN SPR INX ER SYSTEM with comply with such provisions or this permit shall be STATE UC deemed revoked. WATER HEATER IJ CLASS LICENSED CONTRACTORS DECLARATION DISTRICT BY I hereby affirm that I am licensed under provisions of Cbapter 9 W SYSTEM OUTLETS (commandng with Section 7000) of Division 3 of the Business OUtLEIS OVER and Professions Code,and my license is in full force and effect. 3 PER STEMFINAL /Q DATE �r! f VVALIDATION0 O License Number Llt- Class QL FINAL O Cont acIor Date BY G ❑ I am exempt under Sec. B.BP.C. for this reason • Plan check fee Date. PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER43UILDER DECLARATION Name I hereby affirm that I am exempt from the Contractors License Addreas Law for the following reason (Section 7031.5, Business and 9'8.4, A Professions Code): City Tel.No. ❑ I, as owner of the property, will do the work and the # 0 0.0-0.0 5 structure Is not Intended or offered for sale (Section 7041, Business and Professlons Code)_ 2 o c 1 650 CONSTRUCTION LENDING AGENCY oro 0 1 hereby affirm that thate Is a construction lending agency for the performance of the work for which this permlt 4 Issued 02 1 '6-83 (SeG. 3097, Clv. C.). Lenders Name Len iw'z Aran I Gerttfy 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 roperty I spedlon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE f Signature of Permlttee Date