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HomeMy Public PortalAbout4913 HELEO AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby, affirm that I have a certificate of consent to self in- 20-0026 DPW 4/90 ?6A667A sum,o n ceNficate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800, Lab. G) 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 ❑ Certified copy is filed with the county building inspection ADDRESS "[�j C department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. iAJ -�'Q'. (, © COMPENSATION INSURANCE SHOWER OWNER V f aC•e G-erta (This section.need not be completed if the work involved by MAIL 11'/� 1 the permit is for one hundred dollars'($100)or less.) LAVATORY ADDRESS •q`"I 1 � �-1 tea I certify that in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so CITY TEL. NO. as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR , Date. Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this.Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen, CITY TEL. NO. sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION. / O DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ` 9(commencing with Section 7000,)of Division 3 of the.Business OUTLETS OVER 4f/ and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINALt fect. HOSE BIB DATE — VALIDATION License Number Lic. Class ACT)°g O FINAL 3303 43.4105 Contractor Date BY 1 ITEMS E] I am exempt under Sec. TOTAL , V B.&P.C. for this reason ' m �� Plan check fee ' Poo. 43.4C%Date: PLUMBING PERMIT ISSUING FEE$ Q CHANCE °OnE Signature TOTAL FEE '� SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant 0000-0001 11/2 V95 I hereby affirm that I am exempt from the Contractor's License Name 3 s91 °-,-, Law for the following reason (Section 7031.5, Business and 1 Aft 9:33 Professions Code): Address FI, as owner of the property, will do the work and the City Tel. No. 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 to comply with all County ordinances and State laws regulating Plumbing, and hereby authorizerepresentatives of this County to enter upon the above-mentioned poperty for inspection purposes. J I SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION \_ I`Fereb'', firm that I have a certificate of consent to self in- 20_26 DPW a,87 APPLICATION FOR PLUMBING PERMIT r�7� 76A667A Y , I sure,or a certificate of Workers'Compensation Insurance,ora CE 817(REV. 8/86) certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company COUNTY OF LOS ANGELES DEPT.,,OF,•.P_UIBLC-WORKS- . � ^ Certified copy is Hereby furnished. 'F-] FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESS ,J department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY ? Date Applicant WATER CLOSET(TOILET) V V NEAREST '° �®0i �•/ y XEMPTION FROM WORKERS' BATH TUB CROSS STa`�jQ- /\.a "cCERTIFICATE OF Eam . .�.�� COMPENSATION INSURANCE SHOWER OWNER E`RLG (This section need not be completed if the work involved by MAIL. �� 1 /e the permit is for one hundred dollars ($100)or less.) J LAVATORY ADDRESS T� Ave 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 T��,���. �f TEL. NO. ;Pr6-0.J�o as to become subject to the Workers' Compensation Laws: DISHWASHER CONTRACTOR Date Applicant ��i 7t*i�D(/N—// 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 LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION 0 DISTRICT NO PROC SED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS o n 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 (� VALIQJTION fect. DATE U License Number Lic. Cldss O FINA V Contractor Date BY z 9 5 8 A 0 Fj I am exempt under Sec. V # 00,0005 a B.O.C. for this reason �ry Plan check fee ► •► 0 0 58.5 0 � Date: PLUMBING PERMIT ISSUING FEE $ Signature 0.0058,5050 TOTAL FEE .0 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant O 5,06"88 I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and Professions Code): Address I, as owner of the property, will do the work and the City Tel. No. 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 to comply with all County ► ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned proerty fI or ins ection purposes. ICI I -r2 y Sd SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permi tee Date