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Home My Public Portal About5612 GLICKMAN AVE_Plumbing__ WORKER$'COMPENSATION DECLARATION 4187 APPLICATION FOR PLUMBING PERMIT !f Thereby, affirm that I have a'certificate of consent to self In- 76A667A + sUr6:or a certificate of Workers Compensation Insurance,or a CE 817(REV.8/86) certlfied copy jhereof Seca 3800, Lab. C.) . "fl COUNTY OF LOS ANGELES DEPT.-OFPUBLIC WORKS Policy N Company t \ ;� ❑ Certlfled copy Is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING /ems_ JIB ❑ Certified copy Is filed with the county building Inspedlon Ami depart nt. `. NUMBER FIXTURE OR.FTEM FEE _C<:X1TY Data tt Applicant VpNIY r WATER QOSET(TOILET). v� rEARfST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB a CROSS ST. �( W O COMPENSATION INSURANCE SHOWER OWNER (This section recti not be completed 4 the work Invol[ved by (/ MAIL Tv the permit Is for one hundred dollars.(;700)or less.) LAVATORY ADDRESS I certify that In the performance of the work for which this per- SINK 7` mit is Issued, I shall not employ any person In arty manner so CITY �R TEL NO_^ as to becom adb)ect to the Workers' lCLotmperlsdtlotn�Laws. DISHWASHER CONTRACTOR Date t Applicant�ta"� o/Y, ` CLOTHES WASHER ADDRESS `p NOTICE p • PLICANT: If, after making thlrCertiflcate of Ex- SWIMMING POOL RECEPTOR emption,you shouldbecome sublect to the Workers Compen- �y TEL NO satlon provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER +1 lKENSE NO. CLASS LICENSED CONTRACTORS DECLARATION - v DISTR �DBY I herelyy affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license Is In full force.and ef- 5 PER SYSTEM FINAL VALI ION fact. DATE License Number LIC. Class V F Q Contracto Date l� O . f- E]- I am exempt under Sec. W B.RP.C.'for this reason ` letPlan check fee , A Dat°: PLUMBING PERMfT ISSUING FEE; I-SO $Ignature # o o'o e, s 5 TOTAL FEE SINGLEAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant o 0 0 5 8,5 0 Lmi I hereby affirm that I am exempt from the Contractor's License Name I �,.� 7-88 Law for• the following reason (Sectlon 7C31.-5, BGslnas ,and Professions Code): Address. I, as owner of the property, will do the work and the City Tel. No. structure Is not Intended or offered for sale(S¢a n 7Q.", Duslness 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, Clv_C.). Lender's Name Lender's Address I certify that I have read this application and state that the above Informatlon Is correct. I agree to comply with all County ► ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter u on the abovo-m cloned prnprtyor Inspectl pu , � SEE REVERSE FOR EXPLANATORY LANGUAGE Slgn, ;re of Per,S Ittw Date _ � T 78A887 -CE*817 12-84 _ APPLICATION FOR PLUMB G PER;� COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 56 1N -�•(-J COLEMAN W. JENKINS, SUPT OF BUILDING LOCALITY ' )? V FOR APPLICANT TO FILL IN NEAREST CROSS ST. NUMBER FIXTURE OR ITEM EACH FEEf , OWNER WATER CLOSET $1.25 MAIL BATH TUB 1.25 ADDRESS 7 _ CITY C' R } ) TEL. NO.4-<l S SHOWER 1.25 CONTRACTOR LAVATORY 1.25 SINK 1.25 ADDRESS (O g �_ DISHWASHER 1.25 C1TY�'(�M EL. NO. LAUNDRY TUB 1.25 CONTRACTOR'S STATE _ REGISTRATION NO. L COUNTY ❑ CLOTHES WASHER 1.25 DISTRICT NO. G!;� ONE PW155M W15BY WATER HEATER 1.50 GAS SYSTEM OUTLETS 1.50 INDUSTRIAL WASTE APPROVAL C OUTLETS OVER 5 PER SYSTEM .30 j INSPECTION RECORD v t O Col.7 a APPROVALS DATE INSPECTOR'S SIGNATURE PERMIT $ 2 00 UNDER SLAB WORK Z ROUGH PLUMBING TOTAL FEE GAS PIPING I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER PLUMBING. I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/ R PLUMBING FIXTURES LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE O GAS TEST CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF,AND INTEND TO RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. UTILITY CO. NOTIFIED SIGNATURE OF PERMITTEE-(e FINAL VALIDATION ROBERT A. WOOD CK. M.0. CASH SUPERVISING MECHANICAL ENG'R j LAW 0 a 3 6"oo FF$ 2 5 5 D 3.21 5 I IL I I : WORKERS'COMPENSATION DECLARATION Hereby, affirm that I have a certificate of consent to self In- DPW;/® APPLICATION FOR PLUMBING PERMIT sure,or a certificate of Workers'Compensation Insurance,or q g 817(REV. 6/86) certified copy Thereof (Sec: 3800, Lab. C.) - t (J COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Polio No. Company Certlfled copy Is hereby furnlshed. FOR Certlfled copy Is filed with the county building Inspecilon °� T TO FILL IN(PRINT OR TYPE) BUILDING 0 department. NUMBER FIXTURE OR ITtM B FEE LOCALITY Date Applicant WATER CLOSET{TOILET) . � �.AREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST' COMPENSATION INSURANCE �4OWER OWNER ` (This sev lon nkd not be completed If the work Involved by the permit Is fqr bne hundred dollen ($100)or less,} LAVATORY ADDRESS I certtfy that In the Performance of the work for which this per- m(t Is Issued, I shall not employ any person In any manner ao SINK qTY TEL. NO. 6P I ps to become subl to the Workers Compensation kyws. DI51(WASHER CONTRACTOR 4 Date Pppllcant G CLOTHES WASHER ADDRE NOTICE TO APPLICANT: If, after making this 6arlIficote of d emptlon,you should become subject to the Workers'Compen- SWVANNG POOL RECEPTOR CITY TEL fVp. satlon provisions of the.Labor C e, you must forthwith comp- LAN SPRINKLER SYSTEM Iy-with such provisions or this permit shall be deemed revok- STATE LIC. ed. LICENSED CONTRACTORS WATER HEATER L}CENSE NO. CLASS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under prgvltionz of Chapter GAS SYSTEM pU11Ef5 , 0 p 9(commencing with Section 7000)of Division 3 of the Business OAJTLEfS OVER `_46. O and Professions Code, and my license Is In full force and ef- 5 PER SYSTEM FINAL fect. DATE VALIDATION a License Numbgr V'wc. Class C G O _ -FINAL V Q Contractor Date / BY O H 1 am exempt under Sec. U W B.BP.t. for this reason / Plan check fee , I Date " 1 PLUMBING PERMIT ISSUING FEE; Signator. t TOTAL FEE SI LE FAMILY FIOME OWN -BUILDER DECLARATION Plan check applicant I hereby affirm fhot I am exempt from the Contractor's License Name c Law for the following reoson (Section 7031.5,-Buslneu and Profenions Code):.- Address WCT.i I, as owner of-the-property will do the work and the City Tel. No. 37 2-0.5 structure is not Intended cr offered for sale(Section 7044, Business and Profeuions Code). CONSTRUCTION LENDING AGENCY oilTill fL 20 - 50 I hereby affirm that there Is a construction lending agency for fJ,50 the performance of the work for which this permit is issued (Sec.•3097, CIv..C.). Lender's Name- Lender's Addren 1j 1 Z I ceriffy that I have read this application and state that the 7 1 Am 8"41 above Information Is correct. I agree to comply with all County ordingnces qnd State laws regulating Plumbing, and hereby aythorize representatives of this County to enter upon the above-mentioned property for Inspection purposes. 1 SEE REVERSE FOR EXPLANATORY LANGUAGE 1 Signature o —I,.. Date