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Home My Public Portal About5003 GOLDEN WEST AVE_Plumbing__pp— _ WOO FS'COMPENSATION D"RAJIQN.� APPLICATION FOR PLUMBING PERMIT I hereby.! afflim that I hpve a ceFtlflcate of consent to self In- 7DPW 4/87 A sure %P 'certificate of Workers'Gompensatlon'Insurance,or a �811(REV. 8/86) ,ceftifled copy thereof (Sec. 3800, Lab. C'.) Poll cy'-lo:ti Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Certified copy Is here!y furnished. FOR APPLICANT TO FILL IN(PRIM"OR TYPE) BUILDING rl Certtfledcopy IsIl led with the county buHaling Inspecllon ADDRESS (93 L� department. NUMoMR FIXTURE OR ITEM $ FEE LOC1im Date Applicant WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMIPTION FROM WQRKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE (This sectlgn need not be comported IF the work Involved by MAIL the pefmQ H on*for oe hundred dollars 01041 or less.) LAVATORYADDRESS I cerflfy that In the pei-f.ormance of the work for which this per- SINK mit Is Issued, L shall not employ any,person Ln any mo6ner to QTY TEL NO. as to become subject to the Workefs' Compensation Laws. plS4-tWASHF31 CONTRACTOR Date- AppllGant CLOTHES WASHER' NOTICE TO APPLICANT: If, after making this Certificate of Fx- ADDRESS SVhMNPOL RC{ PTOR em t Qn, ou should become subject to the Workers'ComPert- clrY TEL. No. sationlProvlslons of the Labor Codd,you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed feyo STATE UC ed. WATER HEATER LICENSE NO. BASS LICENSED.CONTRACTORS DECLARATIONDISTRICT BY I hereby affirm that I am Iltenaed under provisions of Chapter GAS m AS SYSTEM OIIFTS 9.(corhmencLng with Sectlon 7000)of DIVIsIon 3 of the Byslnew OU➢_ETS OVER . and t Professions Coder and my.license Is In fuH Jorce and of, 5 SYSTEM FINAL DATE VALIDATION a i �, —Z _ 0 License Number LIc. Cl ass�_ r 0 FINAL Ccntrbctor Date x:.. - BY F A am exempt under Sec. V W CL B.BP.0 for this reason 3 Plan check fee Date! PLUMBING PERMIT ISSUING FEE; In Signatures TOTAL FEE SINGLE FAMILY hFOME bWNER-BUILDER DECLARATION Plan check applicant. 5 I hereby affirm that J aryl gxempi from the Contractor's Llcerue • Name /��+ 1 Law for the following reason (Sedlon 7031.5, Euslness-gnd ACCTaT Profes}lons Codej: Addreu, 0 3307 16.5 as owner of the property, wHf do the work and the City Tel. Nd. 1 ITEM /` structure Is not Intended or offered for sale(Section 70dd, _ 1 Buslnea!and ProfessLons Code). { TOTAL 10 CONSTRUCTION LENDING AGRNCY, , . CwCY, ib.SC► I hereby-affirm that there is a conitructlon lending agoncyior the performance•of the work for which this permit is Issued — .12110 (Sec. 3097, Civ. C_).' Lender's Name - OQ0001 111�°I$S Lender's Address — 770 1 All 9:56 I certify that I have read this application-and state that the above Information Iscorrect. I agree to comply with all County , ordlnq a d State laws reg !sting P umbing, and hereby author re ntatlyes of Is Cou to enter upon the above et0H dd property IrYs8ec1 urioo:&W. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign re of Permltt Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING- PERMIT I hNe�ji,'cfflrm-tW I have a certificate of consent to self In- SD 4/87A Rure;or a ctertrflcote of Worken'Compensatron Insurance,or a qE 817(may. a/86) cbrtlfled-copy thereof (Sec. 3800,-Lab..Q_) Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Certified oopy Is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING r�O/j /• _/n� G r Certified copy Is filed with the countybullding Inspection ADDRESS J .J CJ`s ,LJ ✓ departmen1. NUMBER FIXTURE OR ITEM 8 FEE LOCALITY WATER CLOSET(TOILET) / ~ M Date Applicant. — NEAREST p L CERTIFICATE OF DG-MPTION FROM WORKERS' BAT}f TUB 5O CROSS ST. COMPENSATION INSURANCE SHOWER OWNER C c " C. section,need-r of be completed H the work involved by MAIL the permh Is'for one hundred dollars ($100) or less.) LAVATORY k&,,0 — ADDRESS I certify that In the porformance of the work for which this oar SINK mit is I;sued, I hall not employ any pemon Ih any manner so CJf1' TEL NO. 13P as to beco a blect to fhb Workers' Com ensatlon L DISI-WASHER CON-TR/°.CTOR Date App 11ca aoT}iE5 WASHER NOTICE TC L If, after making this Certif,rnt of Ex. ADDRESS SWIMMING POOL RECEPTOR emptlon,you should become subject to the Workers'Compen- �, � � ration provlslont of.the'Labcr Code,you must forthwith comp- LAWN SPRINKLER SYSTEM Ly with.such provisions or this.permit shall be deemed revok- STATE UC old WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. D BY I hereby affirm that I am licensed under prov.lslons of Chapter GAS SYSTEM OUTLETS / 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license Is In full force and ef- 3 PER SYSTEM FINAL VALIDATION fact. DATE. 4 �Z T License Number LIq. Class V FINAL � ntractor Date BY O ElI,am exempt under Sac. i W 8.BP.C. for this reason ACCTAT Plan check fee110.50- Date' PLUMBING PERMIT ISSUING FEE$ Signature 1 ITEM SINGLE FAMILY TOTAL FEE �Q �g`D TI�TRL 11 _ 54 ME HOOWNER-BUILDER DECLARATION Plan check applicant MCK 110.E I hereby affirm that I am exempt from the Contractor's License Name .00Law for the following reason (Section 7031.5, Business and Professions Code): Address I, as owner of the property, will do the work and the City Tel. No. ( 013W-OWI 10/22/90 structure Is not Intended or offered for sale(Section 7044, Byslneu and Professiorls Code). , 3422-5 1 AM 7:51 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.). Lenders 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 repreeenfatives of this County,to enter upon the a v antlers wrty for,fa!qedlon pulp SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Perml to 11