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Home My Public Portal About9044 HERMOSA DR_Plumbing__ YORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT ., I hereby,offirm that I have a'cert ficafe of consent.to self 76A667A Ll insure, or a certificate of Workers' Compensation Insurance, CE 817 (REV. 10/81) - or a certified copy thereof (Sec 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy Nq$kZC Yy6%%?h�pany JLyil°M Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BULLRING ❑ O L' _ D 5 L�p Certified copy is tiled with the county building inspec- ADDRESS 7 I tion department. _ _ NUMBER FIXTURE OR ITEM @ FEE .._..y}�) LOCALITY IR- ter. - Date��8 Applicant /i7C.QlYt/4D E9Z---� WATER CLOSET NEAREST _ CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB - - CROSS ST. COMPENSATION INSURANCE - - OWNE�'f'� �� (This section need not be completed if the work involved by SHOWER the permit is for one hundred dollars 100 or less. - MAIL p (S ) ) LAVATORY ADDRESS 940 9f I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITYi .t TEL. NO. so as to become subject-to the.Workers Compensation Laws. DISHWASHER 73�2_pip CONTRACTO bTJ Date Applicant CLOTHES WASHER I y NOTICE TO APPLICANT: If, after making this Certificate of - ADDRESS S E Exemption, you should become .subject to the Workers SWIMMING POOL RECEPTOR Compensation provisionsofthe Labor.Code, you must forth CITY �'�ILi--TEL. N0011.1571? _ with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM P Y P P STATE T�n LIC: deemed revoked. WATER HEATER LICENSE NO. y� J p CLASS LICENSED CONTRACTORS DECLARATION DISTRI`T Np. P SSED I hereby,affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS — (/JI (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and effect. 5 PER SYSTEM - , ` — FINAL DATE VALI TION 6 0 License Numbers 31JOYS Lic. Class ContocI mCys/ - Date I 2 — D BN O ❑ I amexempt under Sec. - .Lr CL Bi for this reason 10 Plan check fee :Z Date: PLUMBING PERMIT ISSUING FEE$ J' , 3 5 1,7 Ai Signature - - TOTAL FEE 30.. # is • • is o Plan check applicant 1 SINGLE FAMILY PP _ - ( is - 30,501, HOME OWNER-BUILDER DECLARATION Nome e e 3 Q 5 01P I hereby affirm that l am exempt from the Contractor's License Address .I. 1. O-S 5{ Law for the following reason (Section 7031.5, Business and C i Professons Code):❑ ) City Tel. No. , I, 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 offirm'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. Iagree to comply with all County ' ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the , above- ntioned property for ,n pection purpos ,( c� SEE REVERSE FOR EXPLANATORY LANGUAGE Sign ure of'Pe mid tree 1� Date 117 WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT c L`, r!A affirm that I have a certificate of consent to self 76A667A inspire, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy Na. Company - Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS Q 4.1- tion z tion epartment. NUMBER FIXTURE OR ITEM cd FEE LOCALITY Date Applicant WATER CLOSET CJ UD NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER u� j (This section need not be completed if she work involved by SHOWER the permit is for one hundred dollars 5100 or less, MAIL P ( I ) f LAVATORY U v ADDRESS v•, % I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CIT TEL. NO. so as to become subject to the Workers Compensation Laws. DISHWASHER CONTRACT 01 Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS - Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY TEL. NO LAWN SPRINKLER SYSTEM STATE LIC with comply with such provisions or this permit shall be - / . ss deemed revoked. WATER HEATER LICENSE NO. LICENSED CONTRACTORS DECLARATION cu.DISTRICTAO. P CESSED BY` I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS l�s (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER V t 06 6 A and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VAL ATION 9911. License Number Lic. Class FINAL uC W Contractor Date BY /L ❑ I am exempt under Sec so N B.BP.C. for this reason = Plan check fee Signature Date: PLUMBING PERMIT ISSUING FEES Q Q a a a e • TOTAL FEE Z956 Plan check applicant ( Is Is 2 8 5 0 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Nome • • • 2$, rj Q v I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and 0 9. 04-8 5 Professions Code): City Tel. No. ❑ I, 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 to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the ob ya-gtentioned" roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee