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Home My Public Portal About9810 HOWLAND DR_Plumbing__ WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9189 APPLICATION FOR PLUMBING PERMIT tJ fiAfi61A 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 thereof(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, ❑ AQ FOR APPLICANT TO FILL IN(POINT OR TYPE) BUILDING p/O v_ �A Certified copy is filed with the county building inspection ADDRESS G7 department. NUMBER FIXTURE OR REM ® FEE LOCALITY T C Date Applicant / WATER CLOSET / 1557NEAREST //tl�p CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB / CROSS ST. 1�T/7O` N aJr COMPENSATION INSURANCE ASSESSOR (This section need not be completed If the work involved by the SHOWER MAP BOOK PAGE PARCEL OO permit is for one hundred dollars($700)or less.) OWNER 1 I certify that in the performance of the work for which this permit LAVATORY /�, 5Y is issued, I shall not employ any person in any manner so as to MAIL D �WG SINK ADDR became subject to the Workers'Compensation Laws. ESS DISWASHER Date Applicant CLOTHES WASHER J NOTICE TO APPLICANT: It, after making this Certificate of 55� CONTRACTOR _qxL Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. } I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER S_s CL (commencing with Section 7000)of Division 3 of the Business and STATE LIC. Q GAS SYSTEM OUTLETS LICENSE NO. CLASS 0 Professions Code,and my license is in full force and effect. OUTLETS OVER DISTRICT NO. PROCESSED BY O 5 PER SYSTEM License Number Lia Class U FINAL DATE S Z8� VALIDATION LU ?) Contractor Data In ❑ I am exempt under Sec. FINBY AL �o4,%L_� z B.BP.C.for this reason Date: O O 7 d , Signature PLUMBING PERMIT ISSUING FEE$ OJ7� ❑ TOTAL FEE SINGLE FAMILY 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 -- Code): ® ' I,as owner of the property,will do the work and the structure City Tel. No. is not intended or offered for sale (Section 7044, Business - -_'-.-,y v 1 and Professions Code). l CONSTRUCTION LENDING AGENCY I hereby affirm that mere is a construction lending agency for the - - performance of the work for which this permit is issued (Sec. 3097, Civ.C.) Lender's Name .r 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 propert r n„ti. 1,9AinspectiOnose' s. — �9 SEE REVERSE FOR EXPLANATORY LANGUAGE Ai./B 2 ??, tignature of Perrnittee Date WORKERS'COMPENSATION DECLARATION ' APPLICATION FOR PLUMBING PERMIT I hereby affirm that I hove a certificate of cofsrnf'to self 76gyp7. insure, or a certificate of Workers' Compensation Insurance, CE Bq (REV. 10/SI) or a certified copy thereof (Sec. 3800, Lob, C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY _ Policy 7 of cgg/s company G%paukar Cer ified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ,\ Certified copy is filed with th ount buil 'n spec- ADDRESS 1v Ll ZeA tion depart enI NUMBER FIXTURE OR ITEM @ FEE LOCALITY. Date16 Appligant WATER CLOSET NEAREST t .. CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed If the work involved by MAIL the permit is for one hundred dollars ($100)or lass.) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY .—�.� TEL. NO. so as to become subject to the Workers'Compensation Lows. If DISHWASHER l—� CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS -� NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY /r— TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN.SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE �— LIC. deemed revoked. WATER HEATER t�, LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION T NO. PROCSED BY I hereby affirm that I am licensed under provisions of Chapter'9 GAS SYSTEM OUTLETS DISTRICT OV p/ (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �" and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAG �•t DATE VALIDATION er O License NumbLit. Class d, r� G FINAL O Contractor I Date BY ❑ W I am exempt under Sec. B.BP.C. for this reason Plan check fee ► V a Signature Date: PLUMBING PERMIT ISSUING FEE$ D U TOTAL FEE Q . Plun check applicant SINGLE FAMILY '_'. 116'7 A HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address I // o e o o e 5Law for the following reason (Section 7031.5, Business and �7 Professions Code): City Tel. No. o,- 70.50 ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section , �c ' 0 7 Q rJ r 5 7044, Business and Professions Code). f!.2 2— 3 CONSTRUCTION LENDING AGENCY 1 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 certif t I have read this application and state that the ► obo e i for tion is correct. I agree to comply with all County Aab - n Stktelows regulating Plumbing, and hereby re as of this County to enter upon the nrly for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Permittee i^ Date WORKER'S thatIhave a cNSATION DECLARATION 76A667 DPW 9/89 APPLICATION FOR PLUMBING PERMIT -I hereby affirm that I have a certificate of consent to self insure, 76A667A or a certificate of Worker's Compensation Insurance, or a certified cap thereof(Sec. 3800 Lab.C. /Y{'�/' v COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT, OF PUBLIC WORKS DIV. PoTcy No� Pany -C ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ,, / � Cenified copy is filed with the county building inspectionqglo ��, deparm ent. �/��/ ✓ NUMBER FIXTURE OR REM @ FEE / LOCALIADDRESS / O Oat — — Applicarft'� WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) OWNER i. I certify that in the performance of the work for which this permit LAVATORY ri AJ !N is issued, I shall not employ any person in any manner so as to MAIL SINK ADOR BB become subject to the Workers' Compensation Laws. Oz6a,00i DISWASHER / CI ®lt TEL.N _ / y Date Applicant CLOTHES WASHER o NOTICE TO APPLICANT: I7, after making this Certificate of CONTRACTORAJA�LW Exemption, you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRES t provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATIONCI TEL.N . } I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATERYAPriod (commencing with Section 7000)of Division 3 of the Business and STATE LIC. /t Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS OUTLETS OVER DISTRICT NO. PROCESSED BY s, . 5 PER SYSTEM O� i[tcense Number Lic.Class F— FINAL (/Tcu ,c� C /3—�i5 DATE VALIDATION a Contra r Date I am exempt under Sec. FINAL — Zgy 8.8P.C.for this reason I a3 Fri IY f'-NC' "�- li Plan check fee 'F" i - 60 ISI.Ft'e-..t te: T- � S.nnat PLUMBING PERMIT ISSUING FEE$ to 3'�-9� t ?:NECK 4'-.6I i ❑ TOTAL FEE --(. 6 Q Ctif-1 2- ,17111 Plan check applicant i jI?(_Iv—{j{?_71 `;/ 0 r O=1 SINGLE FAMILY HOMEOWNER-BUILDER DECLARATION Name f Ara 1 ,IL 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5, Business and Professions Address Code): r_1 1, 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 above-mentioned property for specs n pur uses SEE REVERSE FOR EXPLANATORY LANGUAGE 02-/8- Signature of Permittee Date �.