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Home My Public Portal About5936 HART AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 20.0028 DPW 9/89 Ap000CAMN FOR PLUM IG PERNT herebyrffirm•that.l have a certificate of consent to self insure, or a cgrtificate)of Worker's Compensation Insurance, or a certified cgpy`ithere of(Sec.3800 Lab. C.) L, y3q 3�s� C COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No. Company Certified copy is hereby furnished. BUILDING �" A,FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS ,;J Ai V Certified copy is filed with the county building inspection d.epartment NUMBER ,; FIXTURE OR ITEM , Q FEE '� l ` LOCALITY Dale_LJ_— Applicant u^ i ✓ V PIUWV� WATER CLOSET.•` i .) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. BATHTUB COMPENSATION INSURANCE r ASSESSOR (This section need not be completed if.the work involved-by,the SHOWER MAP BOOK PAGE PARCEL ` permit is for one hundred dollars($100)or less.) OWNER e 1 I certify that in the performance of the work for which this permit LAVATORY is issued, I shall not employ any person in any manner so as to . SINK MAIL become subject to.the Workers'Compensation Laws. ADDRESS iDISWASHER CITY TEL.NO. Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Exemption,you'should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS - \ provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM v V LICENSED CONTRACTORS DECLARATION CITYZISTEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER — CL (commencing with Section 7000 of Division 3 of the Business and STATE LIC. O ( 9 ) LICENSE NO. S CLASS_. (� Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS �� O, a. OUTLETS OVER DISTRICT NO. D BY �• 0 5 PER SYSTEM C7 aJ 21, O License Number 4✓:a:0 Lia Class 7 5 6 tr T Ei s'- C� FINAL �_ / VAL,�= ,_.� LU DATE. 7U CL Contracto�lrt�V 1 E.i Y ,k i'1(yyda -tl `1 `s 1! siL ° � _ �,- 5 fn ❑ I am exempt under Sec. —• BY FINAL = F•. l —s —'f- i-u' �sjil B.&P.C.forthis.reason / f. H�yi3i Date: Plan check fee - PLUMBING PERMIT ISSUING FEE$ Signature ,2k �v s'si;i i #'r_' _ ❑ TOTAL FEE - _ _ rii�z Plan check applicant � � 4.;�3 i I- _ SINGLE FAMILY ' HOME OWNER-BUILDER DECLARATION Name 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. 1,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.) Lender's Name Lender's Address ,I certify that I have read this application and state that the above information is correct. I agree comply with all County ordinances an e a s regulatin PI mbing, and hereby authorize presentativeeof this Coin y enter upon the above-mentioned prop r inspection purpo s. SEE REVERSE FOR EXPLANATORY LANGUAGE SI of Permitt a Date WORKERS'COMPENSATION DECLARATION n Pnn �(CAV�'®N FOR Pp (I M5PNG PERMP7 1 here 20-0026 DPW 4/90 G=r1 l!"LL, l� Cl lJ L�l�J fl V PERMP7 ll by, affirm that I have a certificate of consent to self in- 76A667A •. sure,.or a certificate of Workers'Compensation Insurance,or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF-PUBLIC WORKS Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �� r ❑ Certified copy is filed with the county building inspection ADDRESS &S A,,P department c NUMBER FIXTURE OR ITEM � Cal FEE LOCALITY T15-A&PL" C-s-'Y Date Applicant WATER CLOSET(TOILET). NEAREST CERTIFICATE OF EXEMPTION.FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER l��A (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS STUN�iS I'certify that in the performance of the work for which t er- SINK 36 mit is issued, I shall not employ any perso any r so CITY `T�h^pi,1S 7 y TEL. NO. Z$6 jp as to become subject to the Worker ' ompe at' a s: ' DISHWASHER ' CONTRACTOR Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making thi Ce tificate of Ex- SWIMMING POOL RECEPTOR ADDRESS hr� / emption,you should become subject to the•Workers'-Compen- CITY /VKs�VJ� TEL. NO. �_7q7Z sation provisions of the Lab--)r'(--ode,you must forthwith comp- LAWN SPRINKLER SYSTEMS ' ly with such provisions or this permit shall be deemed revok- +t STATE r� L� LIC. ! ' ed. WATER HEATER LICENSE NO. cT1� 7 I CLA55 (e+ LICENSED CONTRACTORS DECLARATION DISTRICT NO. P SSED BY I hereby,offirm that I am licensed under provisions of Chapter GAS SYSTEM -OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VA' ATION feet. �L HOSE BIB DATE �^ L� License Number Sq, �`� Lic. Class Z O FINAL // U Contractor 'PAis`—Qj4DCC_ 'Date :5 ZS 7 BY ❑ Q. I am exempt under Sec. o 0. B.&P.C. for this reason i'.'. Plan check fee, :; Dat e�� 7,U.:,_ PLUMBING PERMIT ISSUING FEE$ 4( Signature . . TOTAL FEE .0. SINGLE FAMILY ! . HOME OWNER-BUILDER DECLARATION Plan check applicant ;s )- �" m -` I hereby affirm that I am exempt from the Contractor's License Nome ` Law for the following reason (Section 7031.5, Business and A i S LAm 5cA( Professions Code): Address il�' .t'9¢rt3 i;�;Ec. � ❑ 1, as owner of the property, will do the work and the Cityk)any 1A Tel. No. structure is not intended or offered for sale(Section 7044, ;E,j _s;''=u Business and Professions Code). o . 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 thi application and state that the above information'is correc. gree to comply with all County ordinances and State I Mating Plumbing, and hereby authorizer septa this County to enter upon the abov enti d rt for inspection purposes. ?� SEE.REVERSE FOR EXPLANATORY LANGUAGE Sign ture of mittee Date