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Home My Public Portal About6030 GOLDEN WEST AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION �6A667ADPW9�89 APPLICATION FOR PLUMBING PERMIT I-il eby affirm tliat I have a certificate of consent to self insure, or a,c�Nificate of Worker's Compensation Insurance, or a certified copy thereof(Sec. 3800 Lab.C.) y Company Qom, QJ. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Port No.'LO-04$9604 ❑ Certified copy is hereby furnished. BUILDING " FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 6030, Golden West Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY le aty, Com. Date 1-2-91 Applicant QnFri BTM- iPILIT>hlf'1Cf 3 WATER CLOSET 22 50 NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. 22 COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the 1 SHOWER .7 50 MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) OWNER EMIE IP C2HIIx =CN I certify that in the performance of the work for which this permit 5 LAVATORY 37 50 is issued, I shall not employ any person in any manner so as to SINK MAIL Bar sink 15 00 ADDRESS 250 W. Cc3I11TY�Real become subject to the Workers'Compensation Laws. 2 / DISWASHER 7 50 CITY Acedia TEL.NO.446-5537 Date ApplicantCLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of 1 7 5O CONTRACTOR C?n�1 � Pl . Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS 4265 N. BaLdAdn A provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM VeaE LICENSED CONTRACTORS DECLARATION CITY Fl MMte TEL.NO.443-007$ I hereby affirm that I am licensed under provisions of Chapter 9 1 WATER HEATER 7 150 (commencing with Section 7000) of Division 3 of the Business and 1 GAS SYSTEM [j OUTLETS 7 5O LICENSE N0.231 741STATE LIC.1 CLASS X36-20-16 0 Professions Code, and my license is in full force and effect. OUTLETS OVER DISTRICT NO. PROCESSED BY 231 .741 C36-20-16 5 PER SYSTEM 1�� License Number Lic.Class (/ FINALVALIDATION tl.I Contractor � Date Cin Bras. Plunb 1-2-91 DATE 6 S, L a- � ElI am exempt under Sec. BY AL B.&P.C.for this reason Date: Plan check fee ► Signature PLUMBING PERMIT ISSUING FEE$ 131 OO TOTAL FEE 148 00 Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name M(-'`'^ I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address '•L `" °`' Code): f):_a City Tel. No. ❑ = •��—'°� I,as owner of the property, will do the work and the structure - y - -- 0 is not intended or offered for sale (Section 7044, Business -`AL '—� m 0 and Professions Code). , H j, CONSTRUCTION LENDING AGENCY C! 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.) 1.tI.:On-e I-�tI1.33' Lender's Name Lender's Address I certify that I have read this application and state that the above loo.information is correct. I agree to comply with all County ordinances VdSlaws egulating Plum .r. , and hereby authorize ves County t e r on t above-mentioned m n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE -2- 1 re of Permittee Date WQRKER'SCOMPENSATION DECLARATION 20-0026 DPW 9/89 APPLICATION FOR PLUMBING PERMIT 76A667A I herby affirm that l have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company ❑ Certified copy is hereby furnished. _ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ABUILDING DDRESS�O 6a 3 we�{- ❑ Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM Qo FEE LOCALITY b w Date Applicant WATER CLOSETt NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. C �S ✓�I, COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) LAVATORY OWNER 1A� I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any mann�Sos SINK MAIL ADDRESS become subject to the Workers' onVeription L DISWASHER CITY TEL.NO. Date N1 \� Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after .king this Certificate of Exemption,you should become subject t the Workers'Compensation SWIMMING POOL RECEPTOR I L R provisions of the Labor CodeADDRESS , you must �rthwith comply with such 13 provisions or this permit shall be deemed rLvoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY bpd TEL.NO. '7 > I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER �` J (- (commencing with Section 7000) of Division 3 of the Business and STATE LIC.GAS SYSTEM OUTLETS LICENSE NO. J_ �(� C ASS 1,.- ; V Professions Code,and my license is in full force and effect. OUTLETS OVER DISTRICT NO. y�PROCESSED BY t: ^ 13 5 PER SYSTEM C License Number L Lia Class Z FINAL VALIDATION W_. Contractor , 6 1 �f Date 6 L ^ DATE Z ElFINAL am exempt under Sec. By B.&P.C.for this reason Plan check fee Date: --�; Si nature PLUMBING PERMIT ISSUING FEE$ g r- a El TOTAL FEE l i_i I i_ _ »_..'1. _.. "7 _ Plan check applicant SINGLE FAMILY rl.s�i( HOME OWNER-BUILDER DECLARATION Name •••f'••r'_-• e•• I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address 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 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.) hl 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 regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned prop y for inspectio purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si§nature of Permittee Date