The URL can be used to link to this page

Home My Public Portal About9165 HERMOSA DR_Plumbing__ .. WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9189 I I ' 76A667A. APPLICATION FOR PLUMBING PERMIT u I hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance„or a certified - - copy therepf(Sec.3800 Lab. C.) _ - - - COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company Certified copy is hereby furnished. r ' ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �- Certified copy is filed with the county building inspection ADDRESS Qp7 {yLQQ[A. department. NUMBER FIXTURE OR ITEM ® FEE e IZ C •/�.f�pv LOCALITY'` lel L•Gl Date Applicant WATER CLOSET yQ NEAREST G- C4 CERTIFICATE OF EXEMPTION FROM WORKERS' �- BATH TUB Q �Q CROSS ST. COMPENSATION INSURANCE ASSESSOR (Thissectionneed not be completed if the work involved by the SHOWER MAP BOOK PAGE lif PARCEL permit is for one hundred dollars($100)or Is LAVATORY OWNER w -Lvr." '-sO Wt-p—t— I certify that in the performance of the work for which this permit is issued, I shall not employ any person iri any manner so as toMAIL SINK ADDRESS q �,Q$f3L become subject to the Workers'Compensation Laws. 1 DISWASHER CITY �n,.- 1�� CA TEL.NO. l5 Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of - CONTRACTOR A...._ J •L 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 LICENSED CONTRACTORS DECLARATION CITY TEL.NO. d I hereby affirm that I am licensed under provisions of Chapter 9 - WATER HEATER 41 0 (commencing with Section 7000) of Division 3 of the Business and STATE i LIC. GAS SYSTEM OUTLETS LICENSE NO. CLASS Professions Code,and my license is in full force and effect. (1 OUTLETS OVER DISTRICT NO. PROCESSED BY cc 5 PER SYSTEM �O !i Jr je eA- ' J _ O License Number Lia Class ✓ GGG-I�- 0 FINAL /g �p� V DATE ALIDATION GUJ Contractor Date _ - 5i_t_i .a CL ❑ I am exempt under Sec. BY FINAL -,)�-�, _r7 i I? B.BP.C.for this reason Plan check fee Signature PLUMBING PERMIT ISSUING FEE$ G -D r'tl�` — '� s '� ❑ ` TOTAL FEE /Q SINGLE FAMILY CHAN,F "r" 1 ,!Iti Plan check applicant - 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 Cade): 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). I 'r , 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 - represex atives-of this County to enter upon the above-mentioned prop ,t for inspect looses. SEE REVERSE FOR EXPLANATORY LANGUAGE - - _,T:'Signature ot Permittee p [w�jRKERS7.COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT V Hereby affirm that I have'a certificate of consent to self 76��7A` "� A ' Insure, or,tr.certificare of Workers'Compensa Non Insurance, CE BV(REV. 10/B)) I a orf Nbrfifjed FQPy+thereof (Sec. 3800, Lab, C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY P❑ollcy'No. Company Certified copy is hereby furnished. ❑ . FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING yJ_- Certified copy is filed with the county building'.inspec- ADDRESS' J ri'S-%t4rcfi�Q.� Rdr tion department. NUMBER FIXTURE OR ITEM Cry FEE ,F LOCALITY Date Applicant WATER CLOSET do NEAREST [[> CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 'Q CROSS ST. (:L iI COMPENSATION INSURANCE OWNER (This section need not be completed if t work involved by SHOWER 00 t _-a Jo the permit is for one hundred'dollers0)or less.) LAVATORY MAIL ,f - I f D ADDRESS /�' - 6/J t{/ I certify that in the performance of�h Its'work for wIIC this j. OJ- permit is issued, I shall not employ on person in any anner SINK CITY TEL, NO. �p so as to become subject to the WaAers'Compens'aho Laws. _ / DISHWASHER CONTRACTOR Date "�Ap / /"'- CLOTHES WASHER ADDRESS NOTICE T PPLICANT: If, offer making this Cer' e-,5f ' Exemption, you should become subject the' orkers' SWIMMING POOL RECEPTOR 1t _ Compensation provisions of the LCode, you must forth- LAWN SPRINKLER SYSTEM CITY TEL. NO. with comply with such provisionsns or this permit be - STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS _ LICENSED CONTRACTORS DECLARATION DISTRICT NOD r' OCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ✓ VX (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 SYSTEM0. FINAL VALIION V DATE License Number Lic. Class D T FINAL O Contractor Date BY F ❑ I am exempt under Sec. N 6.8P.C. for this reason Plan check fee ' Z loop. Date: ;2 2 Q �;2'A PLUMBING PERMIT ISSUING FEE$ SD Signature # s s s e e 5 TOTAL FEE 2db FEZ1 I • • 34.50 Plan check applicant SINGLE FAMILY �/ HOME OWNER-BUILDER DECLARATION Name 7� /olli,C, - 3G.506 I hereby affirm that I am exempt from the Contractor's License - 1 (',L Law for the following reason (Section 7031.5, Business and. Address �_` 07,09-85 ' Professions Code): City Tel. No. I, as owner of the property, will do the workandthe structure is not intended or offered for sale (Section pool7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm-Ihal there is a construction lending agency forthe performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Nome Lender's Address certify ih have read this application and state that the ► above i r anon is correct. agree to comply with all County - - ording ces no State laws regulating Plumbing, and hereby authorize a 'esen'a'ves of this Count' to enter upon the ` above entioned p 'Ey for.i nspeciion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P r tree