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HomeMy Public PortalAbout4843 HALLOWELL AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT I hereby: affirm that I'have a certificate of conseni itself in- 76A667A sbr�.,or ct certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) certified copy thereof (Sec. 3800, Lob. 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) L1� i p ��.l fTj � A�/�� Certified copy is filed with the county building inspection ADDRESS Q Vl/ W G V ri/ 1 department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY ����^-•�p �r Date Applicant WATER CLOSET(TOILET) O NEAREST G�-� �P G1 BATH TUBG /1 CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' a ll COMPENSATION INSURANCE SHOWER �1 OWNER ,� 1} J (This section need not be completed if the work involved by V MAIL J�ij the permit is for one hundred dollars ($100) or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- / SINK — 91 mit is issued,I shall not employ any person in any manner so CITY j,/ +CT TEL. NO.104:P lG as tobecomesubject to the Workers'Compensation Laws. DISHWASHER r_ CONTRACTOR Date Applicant CLOTHES WASHER D ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- tion,you should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR em P Y I P CITY TEL. NO, sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER JjQ n LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION V DISTRICT.NO , PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS cOJ�' off/ 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER ° and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL j� S -� ALIDATION � fect. DATE 0 License Number Lic. Class V FINAre4 , Contractor Date BY 4, 0 0 I am exempt under Sec. W rb B.BP.C. for this reason Plan check fee. Poo.Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE 94 5,0 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant c 1 hereby affirm that I am exempt from the Contractor's License Name �, r'r'' JL Law for the following reason (Section 7031.5, Business and `D 0C ACCT a3 Professions Code): AddressfSA lL L AVC-- 307 94.50 1, as owner of the property; will do the work and the city ,0 Gi-ryTel. No.UWI ITEMS structure is not intended or offered for sale(Section 7044, OT Business and Professions'Code). Poo. TOTAL 94. 50 CONSTRUCTION LENDING AGENCY CILECK 1 hereby affirm that there is a construction lending agency for CHANGE .00 the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name FOC13-00131 10/11/N Lender's Address 6184 1 AM 10'-4 I 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ` Signature of Permittee Date ' WORKE;S'.OMPENS,,TIONDECLARATION6 DPW 4/87 APPLICATION FOR PLUMBING PERMIT 76A66 I hereby, affirm that I have a certificate of consent76A66 to self,:n- 7A sur., ora ce-rtificate of Workers'Compensation Ing*urance, o4a CE 817(REV. 8/86) certified copy thereof(Sec. 3800, Lab. 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) �l `�J r? i Certified copy is filed with the county'building inspection ADDRESS S department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY' WATER CLOSET(TOILET) Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM.WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER Isp A) J OC 4_/O (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 per- SINK CITY LC . mit is issued, I shall not employ any person in any manner so Cj TELN S?21 V/ as to becom'e subject to the Workers' Compensation Laws. DISHWASHER - CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- 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- STATE UC. ed. 1;� WATER HEATER /500 0 LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION VT ?TRI T NO. ROE D BY I hereby affirm that I am licensed under provisions of Chapter It GAS SYSTEM OUTLETS Off (/ 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL 9 VALIDATION D' fect. DATE G 0. O License Number Lic. Class U FINAL cc Contractor Date BY �j O t' EJI am exempt under Sec. lUJI CL B.BP.C. for this reason Plan check feeoil. g Date: PLUMBING PERMIT ISSUING FEE $ 0 Signature TOTAL FEE rJ3 .0 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant 5 1 hereby affirm that I am exempt from the Contractor's License Name ('� Law for the following reason (Section 7031.5, Business and ACCT 4 Professions Code): Address 1, as owner of the property, will do the work and the City Tel. No. 3307 43.00 structure is not intended or offered for sale(Section 7044, 1 ITEMS Business and Professions Code). _. . TOTAL 43-00 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction•lending agency for CASH 43.00 the performance of the work for which this permit is issued (Sec. 3097, Civ. C. . CHANGE ■GIS Lender's Name U0���/i / 1�� ��✓ _ 'I�17V 1 `l 1/91 Lender's Address/ �i /�� touJr0000 - I certify that I haveLread, this pa plication and statethat the u `�f 1 AM 9"46' 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 property for inspection pyrposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signa of Permittee Dat WORKERS'COMPENSATIOIJDECLARATION 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT i I'hereby;affirrrFthfft I have a certificate of consent to§elf,in- 76A667A Surb, of a,cc*tificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) cerJfI*d copy thereof (Sec. 3800, Lab. C.) Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) Certified copy is filed with the county building inspection ADDRESS a . G}[( Q W .-;7 ,• department. NUMBER FIXTURE.OR ITEM @ FEE LOCALITY•i• _ - Date Applicant WATER CLOSET(TOILET) NEAREST ,/� ^ CERTIFICATE OF EXEMPTION FROM WORKERS' t BATH TUB CROSS ST. r. -, A 2- A 'CA . COMPENSATION INSURANCE OWNER A4 i SHOWER �vr,, ti' � b (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY, ADDRESSry } ,Z ihf [U► yl I certify that in the performance of the work for which this per- SINK (�- — mit is issued, I shall not employ any person in any manner so CITY '— F ��"`�� TELCigO (44 { as to become subject to the Workers Compensation Laws. DISHWASHER �`OO�i CONTRACTOR Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS SWIMMING POOL RECEPTOR emption, you should become subject to the Workers'Compen- sation provisions of the Labor Code, you must forthwith comp- CITY TEL. NO. p y P- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall-be deemed revok STATE LIC. ed. WATER HEATER LICENSE NO, QASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR SSED Y I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �I � / 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER d and Professions Code, and my license is in full.force and ef- 5 PER SYSTEM FINAL CJ VALIDATION p' fect. DATE 3—/S 1 c-� f�• License Number Lic. Class _ O � N AG 6 FINAL U Contractor Date BY r`G Q 0 ElI am exempt under Sec. LU CL B.BP.C. for this reason ► Plan check fee Dater PLUMBING PERMIT ISSUING FEE $ V Signature TOTAL FEE f2 1,15 U SINGLE FAMILY applicant' check a HOME OWNER-BUILDER DECLARATION Plan cFP p I hereby affirm that I am exempt from the Contractor's License Name "t Law for the following reason (Section 7031.5, Business and _ Professions Code): Address ACCTs - © I, as owner of the property, .will do the work and the City Tel. No. 5307 16.rid structure is not intended or offered forsale(Section 7044, 1 ITEMS Business and Professions Code). CONSTRUCTION LENDING AGENCY , 111TAL 1650 ib c� i I hereby affirm that there is a construction lending agency CASH for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). CHAN9 ..._ _-, . .013 Lender's Name 1V�/?��u� Lender's Address r 1 certify that I have read this application''and state that the 6,35 1 AM 8:52 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 d ove-mentioned property for inspection purposes. $ �V SEE REVERSE FOR EXPLANATORY LANGUAGE Si` ature of Permittee D e