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Home My Public Portal About9941 HOWLAND DR_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof (Sec. 3800, Lab. C.) T F � COUNTY OF LOS ANGELES BUILDING AND SAFETY E Policy No.--' Company Certified copy is hereby furnished. BUILDING i El Certified APPLICANT TO FILL IN(PRINT OR TYPE) � , Certified copy is filed with the county building inspec- tion department. NUMBER FIXTURE OR ITEM @ FEE ADDRESS LOCALITY WATER CLOSET Date Applicant �' NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER J. (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY TEL. NO. LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION � DATE License Number Lic. Class ' FINAL Contractor Date BY I am exempt under Sec. <� B.&P.C. for this reason O Plan check fee ► Date: PLUMBING PERMIT ISSUING FEE$ Ls; Signature L TOTAL FEE . a s 1! • WORKERS'COMPENSATION DECLARATION 76A667A ,yy�� pp p PLUMBING j p p p n �p(�(��p I hereby affirm that I have a certificate of consent to self CE 617 (2-60) H=�P P'LLe 1 C A T 1®.l�I FOR If— L�lid/ M B N G I(—E R Y�II �T insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) COUNTY OF LOS ANGELl'S a BUILDING AND SAFETY, Policy No. Company � ,,, � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ❑ ��t I �L:�t• Y,{ Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM O FEE ADDRESS :department. WATER CLOSET LOCALITY Ci r Date Applicant NEAREST BATH TUB CROSS ST. 4� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER !h i LAVATORY MAIL �j } (This section need not be completed if the work involved ADDRESS f!f W, .-1; �� by the permit is for one hundred dollars ($100) or less.) SINK { CITY �� C i +�'lf• TEL. NO.V-W,71� U /I certify that in the performance of the work for which this DISHWASHER / CONTRACTOR permit is issued, I shall not employ any person in any manner r.r Q so as to becomg subject to the W s' Co p ati L w CLOTHES WASHER ( /J, d t 1 %� ADDRESS c- 17 LC) fRl r� 3� W Date Applicant t yC Z[t ' SWIMMING POOL RECEPTOR y r W NOTICE TO APPLICANT:"If, after making this Certificate of CITY t Z TEL. N 0 S4?( to Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM Z P J STATE •� LIC. ' Compensation provisions of the Labor Code, you must forth- LICENSE NO. �'j) C ASS l with comply with such provisions or this permit shall be WATER HEATER deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. E �WEDB LICENSED CONTRACTORS DECLARATION OUTLETS OVER G I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM i 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATI ' ness and Professions Code,,and my license is in full force and DATE effect. 3`'"ill GCS FINAL /License Nu ber T �j Lia Class �� BY i Contractor Date r F1I am exempt from the licensing requirements as I am a Plan Check fel licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE t� Lic.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's Address License Law for the following reason (Section,7031.5, Busi- City TeL No: 4 0 I,4 A ness and Professions Code): ' ❑ I, as owner of the property, am exclusively contracting #"0 0 0 0.o 5 with licensed contractors to construct the project (Section 7044, Business and Professions Code). 2 o.9 0.10 0 CONSTRUCTION LENDING AGENCY .0 0 ° a 0 v ; I hereby affirm that there is a construction lending agency i for the performance of the work for which this permit is 0 2 1 1 T 8 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 SEE REVERSE FOR EXPLANATORY LANGUAGE " ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-' o d proper. f r inspection purposes. Signature of Permittee Date WORKERS' COMPENSATION DECLARATION ', t' 0 0 0 0 0 0 0 I hereby affirm that I have`o certifi2at&"of eons6nt to self 76Ab67A- G pp�OC�Q��O[>� FOP, pdM�n1[30NJC� PERMP7 nsure, 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 No. Company Certified copy is hereby furnished. F] Certified APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 'L� Certified copy is filed with the county building inspec- ADDRESS . ,�( ^ NUMBER FIXTURE OR IT LOCALITY • tion department. � // �e C� FEE Date A IicaniLs/ vlA��' WATER CLOSET App NEAREST c V CERTIFICATE OF EXEMPTION FROM WORKERS' l BATH TUB CROSS ST.•.oU, � ��k Lpw k VU COMPENSATION INSURANCE OWNERLq�k VVI (This section need not be completed if the work involved'by SHOWER the permit is for one hundred dollars ($100)or less.) I LAVATORYMAIL I certify that in the performance of the work for which this ADDRESS permit is issued, I shall not employ any person.in any manner SINK CITY ^� TEL. NO so as to become subject to the W/oorrkk,/ers'Compensations Laws. DISHWASHER Date t� � pplicant• �( im' `-' CONTRACTOR b &U P..11 CLOTHES WASHER b NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS Exemption, you should become subject to the Workers SWIMMING POOL RECEPTORV*J Compensation provisions of the Labor Code, you must forth- CITY EL. N0. LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. J5ROCESSED_BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ''S r— (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL DATE VALIDATION 7� O _ License N mber Lic. Class ^ZO Qy FINA O ContractPr ate BY U U am exempt under Sec. H B.BP.C. for this reason D Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ V S Signature TOTAL FEE' Plan check applicant SINGLE FAMILY 0 4 a 7 A HOME OWNER-BUILDER DECLARATION Name 1 hereby affirm that I am exempt from the Contractor's LicenseAddress1 0 0 0 0�0 5 Law for'the following reason (Section 7031.5, Business and Professions Code): City Tel. No. 2 0.0 2850 ❑ . I, as owner of the property, will do the work and the 2 ,5 0 u structure is not intended or offered for sale (Section D 7044, Business and Professions Code). 0 x 1 5-8 33 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 D 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. J SEE REVERSE FOR EXPLANATORY LANGUAGE ' 1 114 3111 r Signature of Permittee Dqie