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HomeMy Public PortalAbout5930 GOLDEN WEST AVE_Plumbing__ � C VORKERS',COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT - 20-0026'DPW 4/87 I hereby, affirm that have. certifica e of con4ent,to sr IT in- 76A667A sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV'8/86) " certified -copy thereat-(Sec. 3800, Lab. C. COUNTY OF LOS ANGELES - DEPT. OF PUBLIC WORKS Policy No: ' Company. Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING A ) 41& a Certified copy is filed with the county building inspection ADDRESS /�/ ka department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant ,� WATER CLOSET(TOILET) ` NEAREST CERTIFICATE OF EXEMPTION,FROM WORKERS' _ BATH TUB CROSS ST. COMPENSATION INSURANCE : SHOWER U OWNER -0A1 `�� --� g (This section need not be completed if the work involved by MAIL '2 the permit is for one.hundred dollars ($100) or less.) LAVATORY ` Qv ADDRESSa4/nn '�� / I certify,that in the performance of the work for which this pe SINK `' mit is issued; I shall not employ any person in any mdnner `i 2 O0 CITY y�Q TEL, NO, V/1) to become subi.e t to the Worker 'Comp nsation Laws `// `�_ DISHWASHER' CONTRACTOR v { 7 Date "�• AppIli nt CLOTHES WASHER - NOTICE TO APP/CIT: If, a er m r g thi Ce ate f. ADDRESS emption,you shoubeco subject o the ter 'Co n- SWIMMING POOL RECEPTOR CITY TEL. NO. sation provisions of the Labor Code, you must forthwith comp- ' LAWN SPRINKLER SYSTEM ly with such provisions or-this permit shall be deemed revok- 00 STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. O SSED BY I hereby affirm that I am Licensed under provisions of Chapter GAS SYSTEM OUTLETS 2 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER fe� Professions Code, and my license is in full force and ef- 2 S.PER SYSTEM 6� oO FINAL 'VALI TI N o .7 DATE License Number Lic. Class U FINAL FA r Kull Contractor Date BY O I am exempt under Sec. &&P.C. for this reason , $ Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ tU Signature TOTAL FEE 4 2 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name = Law 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. 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.). Lender's Name' Lender's Address 2' ✓ �� 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 re uI ting Plumbing, and hereby authorize representatives 'of s County to enter upon the abov ITention propert f r nspection purposes. >1 SEE REVERSE FOR EXPLANATORY LANGUAGE Si n re of ter;;itt Date WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby offirm that,I ht3ve a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers' Compensation Insurance, 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 furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDINGd- Certified copy is filed with the county building inspec- ADDRESS NUMBER FIXTURE OR ITEM Q FEE ya tion department. LOCALITY ` � / Date Appl igant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. (� COMPENSATION INSURANCE - SHOWER OWNER (This section need not be completed if the work Involved by MAIL 6� the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS Ij I certify that in the performance of the work for which this permit is'issued, I shall not employ any person in any manner SINK CITY TEL. NO. so as to become subject to the Workers'C P sation Laws. DISHWASHER Zd q © CONTRACTOR Z� Date S2 f L— r� Applicant _CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after ak' g this Certificate of ���� ►-"�' � Exemption, you should become subject to The Workers' SWIMMING POOL RECEPTOR CITY TEL. NO.3 3 Zr7 2 Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM L with comply' with such provisions"or this permit shall be STATE r1 LIC. deemed revoked, WATER HEATER LICENSE NO. v`5 Z 10 7 C S C-36 LICENSED CONTRACTORS DECLARATIONo, DISTRIC�TT NO. D B I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS Lf O (y (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VA (DATION CLI ! ,{0 DATE (0 0_C� License Num r 321 O"1 Lic. Class C---3(a � 0. FINAL Contractor Date t 0 BY I a exe pt under Sec. `U B.&P.C. for this reason a., Plan check fee Dote: PLUMBING PERMIT ISSUING FEE$ 5'0 _ Signature 7. TOTAL FEE I .,T Plan check applicant =ta s'•_(s zt;_! SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name k Nf' '_ 1 i S I hereby affirm that I am exempt from the Contractor's License )i-= ;'' Law for the following reason (Section 7031.5, Business and Address T 03 = E5.0 Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the n pq 1, structure is not intended or offered for sale (Section '(�= 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY a:£.:,- I hereby affirm that there is a construction lending agency for .,i:� !. 1 i3 :i 711�,:',_r , the performance of the work for which this permit is issuedV=i *_ (Sec. 3097, Civ. C.). _ i t _. Lender's 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 reguiating Plumbing, and hereby authorize representatives of this County to enter upon the obo -mentione y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE `t, - 1 1,-V Si/natuto of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers' Compensation Insurance, 76A667A or a certified copy thereof (Sec. 3800, jc, . C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Certified copy is filed with the cou ty b 'Iding ins c- tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date `L Appli4ant WATER CLOSET NEAREST CERTIFI ATE OF EXEMPTION F OM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE U SHOWER OWNER (This section need not be completed if the work Involved by MAIL the permit Is f r,`ne hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in a performance of the work for which this permit is issued, I s II not employ any person In any manner SINK CITY TEL. NO. so as to become subXt orker,' pmpensation Laws. DISHWASHER CONTRACTOR Date CLOTHES WASHER NOTICE TO APPLICAr making this Certificate of SWIMMING POOL RECEPTOR ADDRESS�i ��Exemption, you shosubject to the Workers' CIT TEL.Compensation provisL kor Code, you must forth- LAWN SPRINKLER SYSTEMwith comply with slons r this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. P /�� CLASS LICENSED ORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER O and Professions Code,and my license is In full force and effect. 5 PER SYSTEM FINAL/� r-3,oVALIDATION 8 ,� DATE License Number-1��_Lic. Class 0, ..¢¢���� ti FINAL � ContractorK(, IiZ/aarQ ., Date •ti BY O ❑ I am exempt under Sec. U Lid B.iiP.C. for this reason Plan check feeD(, U) Date: PLUMBING PERMIT ISSUING FEE$ a . Signature TOTAL FEE 0 . Plan check applicant o SINGLE FAMILY � HOME OWNER-BUILDER DECLARATION Name rn 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 1 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.). Lender's 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 Stat law regulating Plumbing, and hereby authorize re resent fives f this Co to enter upon the ab a me i ne opert o ' spection purposes. 1 SEE REVERSE FOR EXPLANATORY LANGUAGE 1, (� Signature of Permitte Date WORKERS'COMPENSATION-DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of-consent,-to self 20-0026 DPW 6/87 v insure, or a certificate of Workers'Compensation Insurance, 76A667A- 'uI or a,certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company ❑ Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING /, Certified copy is filed with the county building inspec- ADDRESS V tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET NEAREST (` ) CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BATH TUB CROSS COMPENSATION INSURANCE OWNER (This section need not be completed if the work involved by SHOWER _rwi 06 the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL y� ADDRESS I certify that in the performance of the work for which this q- permit is issued, I shall not employ any person in any manner SINK CITY /1 TEL. NOkS9 so as to become subject to the Workers Compensation Laws. DISHWASHER ` C/ L4 7 CONTRACTOR � p�r Al DateApplicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY (MgVIWEL. NOJ" with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE CLASS deemed revoked. WATER HEATER LICENSE NO. LICENSED CONTRACTORS DECLARATION GAS SYSTEM OUTLETS DICT OCE BY I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and effect. 5 PER SYSTEM. FINAL r V I AT RI � DATE License Number Lic. Class FINAL BY Contractor Date ®, ❑ I am exempt under Sec. B.BP.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ 10100 Signature TOTAL FEE Plan check applicant Y/4/ �✓ -�C SINGLE FAMILY et HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License (' A Law for the following reason (Section 7031.5, Business and Address ��� 6�! ACCT.'v r �'y Professions Code): City C I. No. [� 3307 7.5.10Lill ❑ I, as owner of the property, will do the work and the 1 ITEMS or structure is not intended or offered for sale (Section 7044, Business and Professions Code). TOTAL 73. 00 CONSTRUCTION LENDING AGENCY CHECK 73o0 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CHANGE . ICI (Sec. 3097, Civ. C.). Lender's Name 13000-3001 6j 8/911 Lender's Address1lf 1 . 1; I certify that I have read this application and state that the ® 9:3.1L above information is correct. I agree to comply with all County ordinances and State laws reg ting Plumbing, and hereby aut a representatives oft is County to enter upon the ove entio d'property for in pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE cam- —lf? Sign9tyJA of P rmitt at