The URL can be used to link to this page

Home My Public Portal About9823 HOWLAND DR_Plumbing__ r WORKER'S COMPENSATION DECLARATION 2 ,0026 DPW 9189 t u ' I heresy affirm that I have a certificate of consent to self insure, 76A667A APPLICATION FOR PLUMBING PERMIT or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab. C.) COUNTY OF LOS ANGELES 1 DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE)❑ ADDR SS Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM ® FEE LOCALITY Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB - t\ V CROSS ST. / COMPENSATION INSURANCE - 7• ASSESSOR y�OCT pgGEO PARCEL�J(� (This section need not be completed If the work involved by the SHOWER MAP BOOK C/ a / permit is for one hundred dollars($100)or less.) / OWNER I certify that in the performance of the work for which this permit b LAVATORY is issued, I shall not employ any person in any manner so as toMAIL SINK become subject to the Workers' Compensation Laws. ADDRESS y DISWASHER CITY TEL.NO. 15�Date Z Applicant - — CLOTHES WASHER CONTRACTOR17 P NOTICE TO APPLICANT: If, after making this Certificate of Vv✓J.B pvy Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS 2 provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION / CITY I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER TEL.NO. 1' 6'ZZX (L (commencing with Section 7000) of Division 3 of the Business and STATE '^n LIC. 0 Professions Code,and license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. 6!a/ CLASS 3� U OUTLETS OVER pp Oj DISTRICT NO. PROCESSED BY Q �" � + / 5 PER SYSTEM G7 OJ rL O License Number 506 ZC9p Lic.Class LC ` .J CC�� F U VALIDATION W DATE _Z—� a Contractor /h�lD�Ir�ri— 6—J2 (n ❑ I am exempt under Sec. BIYAL ? BAP.C.for this reason lime, btA7e�k a /_�(-9Plan check fee ' f: t e Signature rt � PLUMBING PERMIT ISSUING FEE$ Al5 -1 ' ❑ TOTAL FEE l 3 ACCT.TV Plan check applicant - 3307 •-'9�•'=L' SINGLE FAMILY ITEMS HOME OWNER-BUILDER DECLARATION Name ' I hereby affirm that I am exempt from the Contractor's License Law TOTAL .� • e J..} for the following reason (Section 7031.5, Business and Professions Address Code): —9.i5�. ❑ , City Tel. No. CHECK 7- I,as owner of the properly, will tla the work and the structure t� is not intended or offered for sale (Section 7044, Business CHANGE .LIQ and Professions Code). ' CONSTRUCTION LENDING AGENCYn I hereby affirm that there is a construction lending agency for the CICI-I_1-0001 9/1A11Q2 performance of the work for which this permit is issued (Sec. 3097. - _42.1 1 AM 7:46 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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date 20-0026 WOthat I haveCOMPENSATIONcertificate DECLARATION 76A667ADPW 9/89 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 thereof(Sac. 3800 Lab.C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No. Company , ❑ Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 7 Certified copy is filed with the county building inspection ADDRESS Sc.C.3OMr r v department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. ,{ !�' //,, / COMPENSATION INSURANCE ASSESSOR SHOWER �d p/ PAGEOO1/ PARCELG/D1� OO (This section need not be completed if the work involved by the MAP BOOK — permit is for one hundred dollars($100)or less.) LAVATORY OWNER �� I certify that in the performance of the work For which this permit MAIL is issued, I shall not employ any person in any manner s0 as to SINK ADDRESS �j 3 ' become subject to the Workers' Compensation Laws. DISWASHER CITY :a4'14 �D TEL.NO. l I Date Applicant CLOTHES WASHER CONTRACTOR �2 NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith Comply with such ADDRESS provisions or this permit shall be deemed revoked. 5 LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER Q. (commencing with Section 7000) of Division 3 of the Business and STATE LIC. O Professions Code, and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS U OUTLETS OVER DISTRICT NO. PROCESSED BY Q 5 PER SYSTEM /r O License Number Lic.Class �vyt� F— FINAL �i VALIDAT DATE ION a Date Contractor �'7 - y ( i ❑ �. /J CD I am exempt under Sec. FINAL ZBV J/ BAP.C.for this reason Date: Plan check fee ► Signature PLUMBING PERMIT ISSUING FEE$ Q TOTAL FEE D� lG S / ❑ i'iY Plan check applicant y I E- SINGLE FAMILY j.'r�I? HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law 7 L _ ;_, for the fallowing reason (Section 7031.5, Business and Professions Address 1 Cade): City Tel. No. TOTAL 103 e 65 I, as owner of the property, will do the work and the structure '( 1l�-e L,j is not intended or offered for sale (Section 7044, Business and Professions Code). , C_HANG .01-1 CONSTRUCTION LENDING AGENCY l 1`I C I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, i j')I�`_iJ:lil1 (l ��'_; Civ. C.) 5 t_I,a y.`J 1 AM 9, Lenders Name Lender's Address I certify that I have read this application and state that the above Poo.information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this ety to enter upon the above-mentioned proper echo SEE REVERSE FOR EXPLANATORY LANGUAGE o 7- SidnIlrGe. of Perrnitte Date