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Home My Public Portal About9026 HERMOSA DR_Plumbing__ ORoffiKERS�Km ;ha COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 20-0026 DPW 4/90 1 her a, 4ttfi that I have a certificate of consent to self in- 76A667A �7 sun;or a c�rtifimte of Workers'Compensation Insurance,ora - - - [I'LJIII certified copy ihereof.(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES ' DEPT.bF, PUBLIC WORKS' Policy No. Company. Certified copyis hereby furnished. , ❑ FOR APPLICANT TO FILL IN (PRINT OR TYPE). BUILDING Certified copy is filed with the c ui lding inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE L LOCALITY20 av Dote 9 Applicant — WATER.CLOSET(TOILET) 5 NEAREST S CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS St. COMPENSATION INSURANCE SHOWER OWNER "I O (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or.less.) / LAVATORY ADDRESS I certify that in the performance of the work for which this per- - mit is issued, I shall not employ any person in any manner so SINK CITY TEL. NO. as to become subject to the Workers'Compensation Laws. DISHWASHER ' n� CONTRACTOR F9 va fCce- Date Applicant CLOTHES WASHER _ NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS emption,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR CITY TEL. NOJl.3 �6 -ly with provisions ovist the or bar Code;you 11 st be orthwithdeemed comp- - LAWN'SPRINKLER-SYSTEMS -- - _ _ s//YY ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS 25 LICENSED CONTRACTORS DECLARATION DISTRICT No. PROCESSED BY •_�_>. ,— _ _ _ T_. _ _ _ _ GAS SYSTEW 3^OUTLETS' I hereby affirm that am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER o and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL _ VALIDATION fect. �.7 HOSE BIB - DATE ?C y License Number Lic. Class a _ FINAL — O Contractor ` D cte � BY c Q i O 1 am exempt under Sec. zL B.BP.C. for this reg Plan check fee ",.:•r1�'3'� :";;fit w a J N PLUMBING PERMIT ISSUING FEE$ / 7 ti Z Signature �!!� _ j HEMS - ••. TOTAL FEE .j 7v�LJ _ ri AE '� SINGLE FAMILY ' -I I r'— 1.52- HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name �;. ) �'t l Law for the following reason (Section 7031.5, Business and CHANGE .�'- 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 r 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.). ,. 1 Lender's Name I Lender's Address I certify that I have read this application and statethat the ► above information is correct. I agree to comply with all County ordinances and State laws regula ng Plumbing, and hereby - author' a presentatives of this aunty to enter upon the above m io Q operty for in ection purposes. 6' ` ,!s SEE REVERSE FOR EXPLANATORY LANGUAGE ' Signature of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 4 h9rpby,offitrimdhal I have a certificate of consent to s21f 20-0026 DPW 6/67 insure;or a certificate of Workers' Compensation Insurance, 76A667A or o certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company ❑ " Certified copy is hereby furnished. BUILDING fn �'�i ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS �OI�J ��/ o c Certified copy is filed wish the county building inspec- tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET Date Applicant .� NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB ' '� CROSS ST. eys-teG� COMPENSATION INSURANCE SHOWER OWNER' (This section need not be completed if the work involved by / the permit is for one hundred dollars $100 or less. MAIL P ( I ) LAVATORY � ADDRESS I certify that in the performance of the w k (or whi this . permit is issued, I shall not employ any per n in any nnor SINK S CITY TEL. NO. so as to become subject to the Workers'C atio Laws. DISHWASHER �z- CONTRACTOR DatelE TO APP m I CLOTHES WASHER NOTICE TO APP (CANT: If, aft aking this Certificate of /-/n5_- ADDRESS D a.( e , Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY /VLC�✓I C TEL. NO. /��p Compensation provisions of the Labor Code, you must forth- 0 G /y' �- � la�.7 wishcomplywith such provisions or this permit sholl be LAWN SPRINKLER SYSTEM - STATE LIC. deemed revoked. - WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. /� y PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM 3 OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �l and Professions Code,and m license is in full force and effect. 5 PER SYSTEM Y Y FINAL VALIDATION 07 / 7 DATE 0, License Number_69-12 z—Lic. Class - G �-Z r - U �_ ,� I�, � FINAL - Contractor /� Date BY Y 0 a F, ❑ 1 am exempt under .:_moo W B.BP.C. for this real n rt/ a� �- Plan check fee 1 1 �4c Z te: f .1 FHS.. - _. PLUMBING PERMIT ISSUING FEE$ Y _: - - Signatur _ TOTAL FEE Plan check applicant PP SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): Address !„illl_I_-IjIjQ F - City Tel. No. r� 4 r�_ •t ❑. I, as owner of the property, will do the work and the - 7. structure is not intended or offered for sole (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construclion lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name - Lender's Address ' 1 certify that I have read this application and state that the above information is correct. I agree to comply with all County ' ordinances and Slate 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