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Home My Public Portal About6116 HART AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 76A667A I hereby affr�i that It have a certificate of consent to self CE 617 (i-eo) �� U C A T I ON FOR PLUMBING UMBING PERM. T insure, 02 a'certjficate of Workers'Compensation Insurance,or a certified copy thereof(nec.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 ❑ NUMBER FIXTURE OR ITEM O FEE ADDRESS Certified copy is filed with the county building inspection department: WATER CLOSET LOCALITY r Date Applicant NEAREST • BATHTUB CROSS ST. CERTIFICATE OF EXEMPTION FROM'WORKERS' COMPENSATION INSURANCE SHOWER OWNER LAVATORY MAIL (This section need not be completed if the work involved ADDRESS 0- by the permit is for one hundred dollars ($100) or less.) SINKy �i CITY TEL. / �t7 I certify that in the performance of the work for which this DISHWASHER CONTRACTOR permit is issued, I shall not employ any person in any manne 0 so as to become subject to the Workers' C petion La CLOTHES WASHER 1 / _ 9f ADDRESS U Date Applicant 4SWIMMING POOL RECEPTOR d NOTICE TO APPLICANT:-If, after making this Certificate of CITY rZ TEL. NO. (p Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. z Compensation provisions of the Labor Code, you must forth- LICENSE NO. CLASS with comply with such provisions or this permit shall be WATER HEATER deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. P CESSED BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with.Section 7000)of Division 3 of the Busi- FINAL VALIDATION ness and Professions Code, and my license is in full force and DATE' 2 ��j 47 effect. FINAL - _1 License Number Lic.Class BY �r Contractor Date ElI am exempt from the licensing requirements as I am a Plan check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ Q 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. x14'4 Q 5 A ness and Professions Code): I, as owner of the property, am exclusively contracting # 0:0 0 0 0 5 with licensed contractors to construct the project (Section 7044,Business and Professions Code). 2;0 0 5 CONSTRUCTION LENDING AGENCY o 0.0 Q:� I hereby affirm that there is a construction lending agency O 1� '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 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 abovvee--mentions ropes y for inAspee ion purposes. Signature of Permittee Date WORKERS' COMPENSATION DECLARATION p � �p �p p ��/�t� �p 2 �/� •I'hereb affiim.thot,I have"a certificate of ct'nser4 to•se f in- t20-0026 DPW 4/87 ��LS��G d��DUV f�®� lf"LSI�JJUN%lll��UV� �LS�OVU�� Y. CE 817 A Su `'or acertificaie of Workers'Compensation Insurance,ora.. �CE 817(REV. ce4hfied,,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, G,:I AlC /� PY Y 9 p on ADDRESS f (f 11 J deariment. NUMBER FIXTURE OR ITEM," @ - FEE. LOCALITY r W M '?/ '� Certified co is filed with the count buildin ms ecti 'a� S WATER6LOSET(TOILET) i Date".,. ,Applicant NEAREST FROM WORKERS'' BATH TUB' CROSS ST. CERTIFICATE OF'EXEMPTION COMPENSATION INSURANCE OWNER t/ t . . SHOWER v (This''section need-not be completed if,the.work tinvolved by- MAIL /j 0 the Permit isfor one hundred dollars ($100)or.less.) LAVATORY ADDRESS' ! (D I'certify that in the.performance of the `work for which this per- mit is issued 'I shall not employ a'n erson•in on :manner`so •SINK �' ••t`' TEL:NO.' as'to:become"subject to.the Workers'Compe anon laws. - - CITY �� { .� r DISHWASHER f y CONTRACTOR Date Applicant .f/ '(.� �6 'y , CLOTHES WASHER NOTICE.TO APPLICANT: If; after'mciking this.Certificate of.Ex"- SWiMN11NG POOCREC&TOR ' ' 14 emption,_you shoul"d become subject to the Workers'.Compen-, ADDRESSTEL' NO. sation provisions of the Labor Code,you:must forthwith•comp r LAWN SPRINKLER SYSTEM ' / ly with;such'provisions or,-this.perm it shall'be,deemed.revok- ' STATE UC ed:' WATER.HEA7ER ,, LICENSE NO. CLASS LICENSED CONTRACTORS-DECLARATION DISCT NO. P CESSED BY I hereby affirm that I am licensed`underprov,isib ns Ch of: apter G4S SYSTEM OUTLETS0 0 9(commencing with Section 7000)of Division 3 of-the Business OUTLETS OVER and Professions Code, ond'my license is in full force and ef- 5 PER SYS TE _ VALIDATION fact DAT ; O License Number Lic. Class U FINA Contractor Date ' BY s I,a,m,exempt under Sec. �, 0 �. B.BP.C. foi this reason' Plan check fee ;E .PLUMBING PERM #: IT.ISSUING FEE Date: $',:.. t �G Signature TOTAL FEE SINGLE-FAMILY r HOMEOWNER-BUILDER DECLARATION Plan check applicant 1 hereby affirm that;I am exempt from the Contractor's License: Name taw.for the following,reason (Section.703,1.5, Business and ' Professions Code):` Address �1, as owner of the property, will do,the work and the City Tel.,No. structure isnot intended or offered'for sale' ection 7044, Business and Professions Code) CONSTRUCTION LENDING:AGENCY D I hereby affirm.that there is a construction lending'agency for a" 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 h� D ordinances.and State laws regulating Plumbing, and hereby' authorize representatives of this County to enter upon the above-mentioned pr pert 'f inspection purposes. SEE REVERSE:FOR EXPLANATORY LANGUAGE Signature'Or Permittee Date - W-, .bry.,6fr.f1Jrn- DECLARATION A1J"'If"L��CA Il_�_�I1V,. FOR ..1�LUUV111 .�11�1G -'iceEll�'UVU�'T hat I hvecertificate of consent to self in- 20-0026,DPW q/87 S COMPENSATION DECL ertificate"of Workers "Compensation Insurance,oro CE 817(REV. 8/86) certified copy thereof.,(Sec.,3800, Lab C.) t COUNTY OF LOS ANGELES DEPT OF.-PUBLIC,WORKS li Policy No)0-0489604 Company- CNA .`TnS Cri. Certified copy is hereby furnished R, FOR APPLICANT TO FILLIN (PRINT OR TYPE) Certified copy is filed with'the county building inspection ADDRESS. 'epartment.' NUMBER FIXTURE OR ITEM' Lal FEE LOCALITY Date 1 90 „Applicant `O��T p Br'-6� Riumbi NEAREST r I -,::WATER CLOSET(TOILET) :1` CERTIFICATE OF EXEMPTION FROM WORKERS". I BATHTUB ' CROSS'ST. .COMPENSATION INSURANCE OWNER SHOWER' Owen Development (•This•.section need not be completed if the Work involved by MAIL .the permit is for,'one hundred dollars (5100)or less.) LAVATORY ADDRESS I certify that in.tHe pe'rformance.of'the work for which this per- t SINK y CITY TEL. NO. m t is issued, shdll not employ any-person m any manner so " - i. _ as to become 'subject to the Workers Compensation Caws. DISHWASHER cotvTgAcroROwen .Bros. Plumbing., Inc Date Applicant CLOTHES.WASHER ADDRESS NOTICE TO APPLICANT: If, after making this 42 Certificate of Ex- SWIMMING POOL RECEPTOR' ' emption,you'should"become subject to th'e'Workers'Compen- r - SWIMMING provisions of the Labor:Code, you must forthwith comp LAWN SPRINKLER'SYSTEM CITY TEL _ E1 Monte NO 443 0078 iy with',such provisions`or this permit shall,be deemed revok- STATE LIC.' ed. WATER'HEATER. LICENSE NO. 23�-']C}] CLASS C36-20 LICENSED CONTRACTORS DECLARATION TRICT NO. , OCESSED BY I.hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS (a/ 9(commencing with Section 7000)of Division.3 of the Business ' OUTLETS OVER DI+ and Professions Code, and my license is in full force and ef- FI--NAS y fect f , t r / O ' S PER SYSTEM ALIDATION-, License Number 231-741- Lic Glaes C36-20 FIN 's V !l BY tt ✓� Contra�torOwenrBros. 'PlumbD>3,� 9 30-91 ({ {' O /a V O I am.exempt under Sec v /�jlt ( 7 �� ',: W 77 B &P.0 forthis reason to Plan check-fee ' Date: PLUMBING-PERMIT ISSUING FEE$ D Signature TOTAL FEE ��. SINGLE-FAMILY ' HOME OWNER-BUILDER DECLARATION-' Plan check applicant i hhereby affirm that I am exempt fromrthe Contractor's'License Name " t� rJ'7' 8 Law for the following reason,(Sddion 7031:5 Business and' ;. ACCTA Professions Code):, Address — 3607, C ) . 4.50 , I, as owner of 'the' will will do"the work and the City Tel No. 1 ITENS r. structure'-is n'ot intended or offered for.sole(Section 7044; Business and Professions Code) , TOTAL 50 _ CONSTRUCTION LENDING AGENCY `; _ .• ;..}_ . - -" '::'"'; :' �•HEC(�i - :7zt°��t.l D I'here byaffirm that there is a construction lending agency for '. CHANGEl the performance.of.the work for which this permit is issued= (Sec..3097, Civ. C:,). , Lender's Name 0000—CINCH 10/23/8 Lender's Address 6356 1 1 certify that I.have read this application and state that-the above information is correct. I agree to'com,ply with all County D ordinances and State•laws_reguloting Plumbing, and-hereby'. ,pyt rize r presenia fives' this County to enter upon the a ve-m net(-pr e r inspection purposes. - N-Z .SEE REVERSE.FOR,EXPLANATORY LANGUAGE fig 're of Permit, Date