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Home My Public Portal About6129-6131 GOLDEN WEST AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 78A867A APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self ce eii (2-SO) insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800, Lab.C.) `fl COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.R9�Company FAIRMI12M INSURANCE 2 _! 3 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING T ADDRESS 6 -N• GOLDEN WEST ❑ Certified copy is filed with the leunty building inspection NUMBER FIXTURE OR ITEM • FEE CITy, CAO 91 department. a /1 WATER CLOSET e0 LOCALITY TENpLL780 Date6AI/82 Applicant �J NEAREST BATH TUB CROSS ST. GARIBALDI CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNERS & MRS'• RTTFP METZ (This section need not be completed if the work involved LAVATORY MAILADDRESS10046 UNROSE STREET a by the permit is for one hundred dollars ($100) or less.) SINKTEMPTS ('.TTY O 2 CITY TEL. NO Q I certify that in the performance of the work for which this DISHWASHER p OWEN PLUMBING cc O permit is issued, I shall not employ any person in any manner '� S CONTRACTOR so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER I— Date Applicant ADDRESS 0 E. MONTECITO LUU NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR CITY TEL. NO � Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE STIMRA SADRE LIC. C2 Compensation provisions of the Labor Code, you must forth- LICENSE NO. 416071 CLASS C+-36 with comply with such provisions or this permit shall be Z WATER HEATER deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PR ESSBD BY LICENSED CONTRACTORS DECLARATIONOUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL � ness and Professions Code, and my license is in full force and DATE -® � m� VALIDATION effect. License Number 41� ?1 Lic.Class CeFINAL p BY Contractor )4,' -Sale 6/21/QZ z I a exempt from the licensing requirements as I am a Plan check fee �✓ licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE Lic.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's Address License Law for the following reason (Section.7031.5, Busi-. City Tel.No. 22 4 4 4,8 A ness and Professions Code): I, as owner of the property, am exclusively contracting '{( 0.0 0 0 o 5 with licensed contractors to construct the project 2 0 3250 (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY o ° 1 325020: I hereby affirm that there is a construction lending agency1 -82 for the performance of the work for which this permit is issued (Sec. 3097,Civ.Com.` Lender's Name MONTEREY PARK NATIONAL BANK Lender's Address PARK, cA. 91754 I certify that I have read this application and state that the above information is correct.I agree to comply with-all-County SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-men honed property for inspection purposes. s> > gnature of Permittee Date WORKERS'COMPENSATION DECLARATION CfA,s1 A APPLICATION FOR PLUMBING P E R M I T I hereby affirm that I have a' certificate of consent to, self cE,.s» (z-eo) insure, or a certificate of Workers'Compensatiod-Insurance,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 e ❑ ADDRESS Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE q department. LOCALITY WATER CLOSET Date Applicant NEAREST BATH TUB CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNERr—� LAVATORY MAIL (This section need not be completed if the work involved ADDRESS by the permit is for one hundred dollars ($100) or less.) SINK CITY TEL. NO. —��1 a I certify that in the performance of the work for which this DISHWASHER V permit is issued, I shall not employ any person in any manner CONTRACTOR so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER ADDRESS fJ O Date Applicant SWIMMING POOL RECEPTOR NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO. LL�� Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STAT LIC. Compensation provisions of the Labor Code, you must forth- WATER HEATER LICENSE NO. 3 �� CLASS C_p7 2 with comply with such provisions or this permit shall be deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. P OCESSED BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL ness and Professions Code, and my license is in full force and DATE VALIDATION/� �� effect. p� Q Number-3-C12--n C 1 2 FINAL sd"" License Number Lic.Class. J72 BY BY 's Contractor Date F1I am exempt from the licensing requirements as I am a Plan check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE Lie.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION INarne I hereby affirm that I am exempt from the Contractor's Address License Law for the following reason (Section,7031.5, Busi- City Tel.No. 5 9 0,8 A ness and Professions Code): ElI, as owner of the property, am exclusively contracting '#10 0 0 o o 5 with licensed contractors to construct the project (Section 7044, Business and Professions Code). 2 °-2Q50 CONSTRUCTION LENDING AGENCY 00020,5005 I hereby affirm that there is a construction lending agency 2 7—8 2 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 ication and state that the above in ation is correct.I agree t comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE ordi nces and State laws re ing Plumbing, and hereby aut ize representatives is County to enter upon the above-men r -for.inspection purposes. Signature Permittee Date