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Home My Public Portal About6133-6135 GOLDEN WEST AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION CE 81 A I APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a' certificate of consent to self CE 917 (z-so insure, or a certificate of Workers'Compensation Insurance,or "fl a certified copy thereof(Sec..3800,Lab. C.) .. COUNTY OF LOS ANGELES BUILDING AND SAFETY , Policy No.�,,LL Gp Company FAIMCM INSURANCE ejX?2 -,v— C /.-f's— ) Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ADDRESS N.• GOLDEN WEST O Certified copy is filed with e c unty buildin inspection NUMBER FIXTURE OR ITEM • FEE de artment. 0� LOCALITY TRIM CITY, CA, 91780 WATER CLOSET NEAREST Datel6yl�ay Applicant s BATH TUB CROSS ST. GARIBALDI CERTIFICATE OF E PTION FROM WORKERS' COMPENSA ION INSURANCE SHOWER OWNERj . & MRS. RILEY METZ LAVATORYMAIL (This section need not be completed if the work involved �' ADDRESS 10046 LynosF. sum by the permit is for one hundred dollars ($100) or less.) Z SINK CITY TEL NO. O 1 -574-1399I certify that in the performance of the work for which this DISHWASHER U permit is issued, I shall not employ any person in any manner CONTRACTOR Qi' PLUMBING so as to become subject to the Workers' Compensation Laws. 2 CLOTHES WASHER ADDRESS E MaNnCITO AM 0 O Date Applicant a SWIMMING POOL RECEPTOR U NOTICE TO APPLICANT: If, after making this Certificate of CITYSIERRA MADRE TEL. NO. Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. fn `Compensation provisions of the Labor Code, you must forth- LICENSE NO.416071 CLASS Ci-36 � with comply with such provisions or this permit shall be WATER HEATER19 I deemed revoked. y GAS SYSTEM OUTLETS DISTRICT NO. YOCESSED Y I LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATION ness and Professions Code, and my license is in full force and DATE / p' effect. 3 License Number4�� 71 — Lic.Class. C-36 BY FINAL Contractor �' Date (1,12111PF1 I a exempt from the licensing requirements as I am a Plan check fee Id licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ J 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 I Address License Law for the following reason (Section.7031.5, Busi- City Tel.No. ness and Professions Code): 1, as owner of the property, am exclusively contracting �'7 A with licensed contractors to construct the project # 0 0 0 o o 5 (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 2.0 1 3250 I hereby affirm that there is a construction lending agency 0 0 1 3 2..ir' 0*5 for the performance of the work for which this permit is issued(Sec. 309�7i.,Cav r W PAW NATIONAL BANK 0421 -82 Lender's Name VlY1�i!{i'r� Lender's Address 2 0 S. GAMELD. 1_r1ANTt+'M PCA-91754 I certify that I have read this application and state that the above information is correct.I agree fo coin'ply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby authorize rpresentatives of this County to enter upon the abo -me coned grope inspection purposes. ignature Permittee Date t �NORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I herebF',affirm that I have a certificate of consent to self 76A667A insure;�"a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) r3c 6•certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY f Polic � ompany Certified copy is hereby fur shed. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY 17 Date,4,-1 ApplicanwJ LQ WATER CLOSET NEAREST r CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER (This section need not be completed if the work involved by MAIL SHOWER ` n the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS (ii S5_ (0024iF A) I certify that in the performance of the work for which this `�' permit is issued, I shall not employ any perso in any manner SINK CITY f - TEL. N so as to become subject toApplica kers Co ens on Laws. DISHWASHER �.•_ S Date r CLOTHES WASHER ADDRESS NOTI E TO APPLICANT: If, of er making this Certificate of SWIMMING POOL RECEPTOR C_ Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- CITY TEL. NO. LAWN SPRINKLER SYSTEM with, comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. % CLASS LICENSED CONTRACTORS DECLARATION DISTRI T NO. �R CESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 4__ (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER "' 1 r and Professions Code,and my license is in full force and effect. 5 PER SATEM FINAL VALI ATION _ DAT License NumbsFIN 1 � BY icnW0-9 �AgX151 Date �j LLY ❑ - I am exempt under Sec. B.BP.C. for this reason Plan check fee g Date: PLUMBING PERMIT ISSUING FEE$ .2 1 8 7,3'A Signature TOTAL FEE #'o o o-o o 5 _Ij d Plan check applicant SINGLE FAMILY I .o o 3 Q 5'0 HOME OWNER-BUILDER DECLARATION Nam o o o30,5 0 U I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and �` 4 1 8 5 Professions Code): City D �` Tel. N�( ❑ I, as owner of the property, will do the work and +a structure is not intended or offered for sale (Sectir n 7044, Business and Professions Code). pop CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency f)r the performance of the work for which this permit is issu:d (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 Bove-mention pro y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE nature of Permittee ate ��