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HomeMy Public PortalAbout6114 GOLDEN WEST AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT a('I•.hereby affirm that I have a certificate of consent to self 76A667A ,i.rtsure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) u or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING / �"/ c ^...., Certified copy is filed with the county building inspec- ADDRESS / t yV L S tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY G( Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER �5L (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) , LAVATORY ADDRESS �- I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. F'vj C so as to become subject to the Workers'Compensation Laws. DISHWASHER J � q�� CONTRACTOR � Date k _Applicant.) �1 L�N I56U_ CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY TEL. NOL r LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. R ESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER C and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALI ON DATE ar License Number Lic. Class O FI Contractor Date F I am exempt under Sec. O� U B.&P.C. for this reason W Plan check fee ► o. Date: PLUMBING PERMIT ISSUING FEE$ Z Signature 16 TOTAL FEE 2509 1 Plan check applicant # 0 0 0 0 0 SINGLE FAMILY i CC C HOME OWNER-BUILDER DECLARATION Name b r 155 ILL I o a 2 a 5 0 1 hereby affirm that I am exempt from the Contractor's License p� O �c,1 Law for the following reason (Section 7031.5, Business and Address & /V • & W f o o o '2 a 5 Q 5 Pro essions Code): City TUAPLE C Tel. No. S—U!g I, as owner of the property, will do the work and the `� 07,21 -a.-86 structure is not intended or offered for.sale (Section I' �~�pD© 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 I certify that I have read this application and state that the above information is correct. I agree to comply with all County poll ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the ab ye'MZtioneApror for jPspection pur oses. � ySEE REVERSE FOR EXPLANATORY LANGUAGE / Signotur of Pe ittee Date WORKERS' COMPENSATION DECLARATION A � I hereby affirm that I have a certificate of consent to self 76A667A A%PPLI TI PLUMBING `�®CQAAMI ■T insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LCIS ANGELES / BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished.❑ BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Certified copy is filed with the county building inspec- 14 tion department. NUMBER FIXTURE OR ITEM On FEE LOCALITY Date A licant WATER CLOSET pp 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 the permit is for one hundred dollars($100)or less.) , LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. so as to beco e subject to the Wor er 'Compen n Laws. g DISHWASHER l CONTRACTOR NzDate� Applicant CLOTHES WASHER OTICE O APPLICANT: If, after making th Certificate of ADDRESS Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY TEL. NO. LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed.revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ?' and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL Q VALIDATION DATE License Number Lic. Class �o FIN Contractor Date BY ❑ Ey I am exempt under Sec. � 8.8P.C. for this reason Plan check fee Date: Signature PLUMBING PERMIT ISSUING FEE$ v S� TOTAL FEE SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address c Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. 0 ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section `i c c 7044, Business and Professions Code). 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.). 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 PP ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-m htioned proper or inspe ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of PermitWe bat& WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. r ) FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING El Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant / WATER CLOSET NEAREST o` 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 the permit is for one hundred dollars($100)or less.) / LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK s CITY TEL. NO.W-0 y so as to become subject to the Worker Compens ti n Lows. / DISHWASHER �� 6�f` [� CONTRACTOR Date ApplicarJL , L"U ® CLOTHES WASHER n ADDRESS NOTICE TO APPLICANT: If, after making thi Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL. NO. with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER ,,,.s LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS v �.� (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER >_ and Professions Code,and m license is in full force and effect. 5 PER SYSTEM y Lt VALIDATION DATE License Number Lic. Class FINAL Contractor Date BY 4A I am exempt under Sec. � Nd B.BP.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE ` L;2 5 6 A Plan check applicant ; SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name 2 <-'c 5 I hereby affirm that I am exempt from the Contractor's License Address y Law for the following reason (Section 7031.5, Business and Prof ons Code): City Tel. No. 1 LJ I, as owner'of the property, will do the work and the structure is not intended or offered for sale (Section Q n 1 n— 4 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 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-mentione pr perms for inspection purposes. o SEE REVERSE FOR EXPLANATORY LANGUAGE Signature 0 ermMee Date