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HomeMy Public PortalAbout5570 GLICKMAN AVE_Plumbing__ ?-WORKERS'COMPENSATI-ON bECLARATION x 4/87APPLICATION FOR PLUMBING PERMIT I herB'by, affirm that I have a certificate of consent to self In- 76AWA Vor o,certificate of Workers'Compensattortlnsurance,ora C�817(REV. 8/86) 4ad copy thereof (Sec.9800, Lab. C:) _ Pollf No. CompanyCOUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS cY E] Cerilfled copy. Is hereby furnished, BUILDING - FOR APPLICANT TO FILL IN(PRINT QR TYRE) ( `( CerLlfiad copy Is 41led with the countybulldfng Inspectloh ADDRESS L department. NUMBER FIXTURE OR{TEM 8 LOGIIITY Dane_ AppflcaAl WATER CLOSET(T01LEf) NTAREST CFRTIFICATE OF EXEMPTION FROM WOkKERS' BATH TUB CRASS ST COMPENSATION INSURAI4CE SFIOWER dwNEJR (Thli section need not be-completed H the work invblvsld by G �� the p4MH is for one hundred dollars (V00)or leas.) LAVATORY IpRE55 ' I certify-that in the performance of the work for whl'ch this per? mil.Is Issued, I shall not employ any person In any mariner so ' SINK O 1Y (� pi0. � }� as-to become su ) to the Workers Compensation Lows. DISHWASHER 7� . CONTRACTOR Date Applicant - CLOTHFS,WASNER ADDRESS t40:11 APPUCANT:if, after making 1 Certlfica of'Ex- WIMMINCT POOL kECFPTOR amption,you'should becoMe subI�act to the Workers' ompen NO CITY satlon provisions of the Labor Code, you'must forlhwlth co-Pnp LAWN$pRINKLER SYSTEM ly wItH such provlslons or this permit shall be deemad.re_vok- STATE L}C. �- � WATER HEATER. -L NO. CLASS LICENSED CONTRACTORS.D�dARATIOIJ. DISTRI NQ Y I Hereby affirm that I am licensed under provfsions.of Chapter GAS SYSTEM OUTLETS Y 9(,ammpnclrig with Sect Ian 7000)of Dl vision 3.of I-Ke 8uslness OUTLETS (f o and Professions Code, and my license Is In full force and ef- 5 PER SYSTEM FINAL fact. DATE !/ VALIDATION a Llcense'Number Lic. Class _ O � UV FIN O Contractor Date B am exempt under Sat. W B.BP.C. forthis reason Plan check dee ► Dates PLUMBING PERINII'ISSOING FEE$ Signature TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDEk'DECLA)ATIOfI Plan check appllcprSt I hereby gfflrm that I am exempt from the Contractor's Ll4enseName 5 y c Law for the following reason (SeOlon 7031.5,,Business bnd ACCT Prgfaaslons Code): Add` .r t 3307 22.50 I, as owner of the property, wHI do the work and the City Tel. No. 1 IT EMS �trucfure Is not intended or offered for ale,(Sedfgn 7044, Business end Professions Cgde). f TOTAL o0 . -OO-N 7RUCTION LENDING AGENCY Y , OECK 22.50 I horafpy affirm thabthere Is b construction tending agency for. The performance-of the work for which this permit Is Issued t .� (Sec. 3097, qv. C,)_ Lender's Name O9/25/89—W01 gf25/ La.nder's Address,s +.��M 1 Aft :32 1 certify.that I have reed this appllcatloh and state that the above information is coned.1 agree to comply with all.County ► ordinances and State laws regulating Plumbing, and hereby authorize representatives of this-County to enter upon the above-mentlon'ed prope for Inspaptlon purpgs4M. - a SEE REVERSE FOR EXPLANATORY LANGUAGE §1 at ro f Permlttee Ir Da6. YyORKERS'COMPENSATION o�ECLA 'nse APPLICATION FOR PLUMBING PERMIT I fl�reby affirm that I haves Seritflcate of consent to self 20-OQ2E DPW B/87 Insure, or a certificate of Workers'Compensation Insurance, 7BA887A . o+ q certlfled copy thereof (Sec. 3800, Lab. C ) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS PolollqfNo. Company Certified copy rt hereby fvmished. ❑ FOR APPUCANT TO F3 U.IN(PRINT OR TYPE) �DD�R&SS Cwllfied•copy Is'-filed with the,county building irspec- flon deportment, NUMBER FIXTURE OR TEM p FEE LOCALITY (� /z Dote •Appllgant WATER C10SEr © • WARgT C- CERTIFICATE OF MPTTON FROM WORKERS_' BA1N TUB CROSS SC. 6XF COMPENSATION INSURANCE O''N'IIER Tjk r O 7 (Thlfi section need riot be completed If the work imhohed by MAY the pd mtt h for one hundred dolkrs($100)or lees.) � LAVATORY ADDRESS d I cwi fy that)n the perfortnance of the.work for which this `{ permit Is Issuid, I shall not employ any person In any manner SINK CITY T TEL �' 3 so as to yy�Ject to the Workers Compensation Laws. DISHWASHER / CONTRACTOR Da» Iltant aOTI ES WASHER ADDRESS NO TQ if, after maki g this CertlfJcne of SWIMMING POOL�TOR Exemption, you should become sublect to the Workers' my TB_ NO Compensation provislons of the Labor Code, yqu must forth- LAWN SPRINKLER SYSTEM with comply with such provlsldns or this permit "Il be STATE LHC deemed revoked. WAYa HEATERLK: NO. LICENSED CONTRACTORS DECLARATION BY affirm Ibereby arm that I am iter lcenYed under provltlons of Chap9 GAS SYSTEM OUTLETS 1 61 (commencing with Section 7000 of DWIslon 3 of the Bualhess OUTLETS OVER and ProfessFons Code,and my Ilcenee Is In full forcaandef t. 5 PER SYSTEM FINAL VALIDATION 1 00 Llc. Class DATE 11 2tL 47 License Number �+ FI Cdntroctor Date I am exeropt under Sec B.3P.C. for thu reason Plan checkfee Da to PLUMBING PERMIT ISSUING FEE$ Signature _ TOTAL AE Plan check appllcan4 SINGLE FAMILY 5HOME 6WNER-BUILDER DECLARATION Name I hereby affirm thtat'I am exempt from the Contractors Llcerue Address 0t _ r.�r► Law for the foHowIng reason (Section 7031.5, Buslnesa and . lL Pro essloha Cade): City Tel. Na46e . �— I, as owner of the property, will do the work and the 1 ITEPIS turoIs not Intended or offered for tale (Section r � - � Butlna*k and Profeaslons.Code). CONSTRUCTION LENDING AGENCYCWCK SCA I hereby afRrrh that th"Is a construction Igndlhg agency for �- the performance of the work for which thit perrglt Is lesued # (Sec. 3097,Crv. C.} • Lender's Name - tw8t,1VJSJ ZLl1 sl 7/89Lender'tAddre"' 4914 1 AM $13+f I certify that,I have read this application'and state that the above mr Irrfoon Is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize repre;entatives of this, County to ehter upon the above-mentlooed'property for Inspection purposes.. EEE REVERSE FOR EXPk,ANATOIRY LANGUAGE Sibnaturof6f Permittee j Data rPLUMBING . 1 DEPAR32EENT OF COUNTY ENGINEER DIVISION OF BUILDING AND SAFETY PERMIT APPLICATIQ11 } COUNTY OF I.OS ANGEL FY3 BUILDING WILLIAM J. FOX. CouwrY ENa1N[[R ADDRESS FOR APPLICANT TO LL IN LOCALITY BUILDING NEAREST ADDRESS i CR088 ST. DIST@ICGROUP I ZON¢ PKRU IT LOCALITY S NEAREST ORO as ST. RE0E1 ED BY RnO fK Iupogdon DATE ISSUED OWNER �/�.CiiC.�i�� /`f t/$,e �� ✓�� PAIL INDUSTRIAL ADDRESS WASTE APPROVAL CITY T[L N0. INSPECTION RECORD PLUMBER ADDRESS OITY T[L N0. ftTAT9— LICENSE N0. []COUNTY PERIM FEES J IJ MN R Tyr[ OF rix-ru K OR ITEM rQ Q WATER CLOSET(TOILM am BATHTUB ! � 0 SHOWER LAVATORY(WASH BASIN) ! IM KITCHEN SINK ! am LAUNDRY TUB OR TRAY ! Gals SLOP SINK ! 9.99 FLOOR SINK ! O d1 FLOOR DRAIN Q 110 DISHWASHER ! 4.80 DRINKING FOUNTAIN URINAL Q 1.10 GAS SYSTEM OUTLM I.00 WATER HEATER ! 1.10 MISCELLANEOUS APPROVALS DATE INBPRGTOR'S SIGNATURE UNDER SLAB WORIC PERMIT 1 OO ROUGH PLUMBING GAS PIPING �. TOTAL FEE I HEREBY ACKNOWLEDGE THAT I HAVE HEAD THIS APPLI- GAS VENT CATION AND STATE THAT THE ABOVE ISCORRECT AND AGREE HOT WATER HEATER TO COMPLY WITH ALL COUNTY O@DINANDES AND STAT Wd REGULATING PLUMBING. PLUMBING FIXTURES I HEREBY OERTI RLY REGISTER AND/OR LIOfiN6 pEQUI d ANGELES CO GAS TEST AND STATE LIFORNI I AM THE LEG WN- ER OF TH OVE D E DENTIAL UTILITY 00-NOTIFIED i 81GM RE OFP MTT FI A MM DBS IT Cd b 12-53