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Home My Public Portal About6112 IVAR AVE_Plumbing__ DECLARAT WORKER'S COMPENSATION ate of consent to 76A6 7A DPW 9/89 APPUCATMN FOR PLUMBNG PERMT Ijht:reby affirm that I have a certificate of consent to self insure, �I u� , or a cer!ificate 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.❑ BUILDING J�FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS U7( T- r Aver Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY `��.r� Date Applicant / WATER CLOSET `1 NEAREST. ILl 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 D MAP BOOK `/ PAGE OOZ PARCEL U/ permit is-for one hundred dollars($100)or less.) / OWNER I certify that in the performance of the work for which this permit LAVATORY Co-i^fnet1 r Q.r is issued, I shall not employ any person in any manner so as to SINK MAIL � 1 Ave , become subject to the Workers'Compensation Laws. ADDRESS �,� V_ S .t-a DISWASHER CITY JCC�� .�; TEL.NO. Date Applicant CLOTHES WASHER OC NOTICE TO APPLICANT:- If, after making this Certificate of 7 CONTRACTOR Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. �- I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000) of.Division 3 of the Business and STATE LIC. lO GAS SYSTEM OUTLETS �y LICENSE NO. CLASS Professions Code,and my license is in fullforceand effect. - �/ V OUTLETS OVER DISTRICT NO. PROCESSED BY 5 PER SYSTEM _ JS Y 0 License Number Lic.Class V (! s U FINAL �� VALIDATION � DATE • Contractor Date C0 ❑ I am exempt under Sec. FINAL ZBY B.&P.C.for this reason Plan check fee Date: SignatureIse PLUMBING PERMIT ISSUING FEE$ p ❑ TOTAL FEE Plan check applicant - SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name, J ERA.ci. I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address, i? y e f Code): City Tel.No. a Ts CIn I,as owner of the property,will do the work and the structure i 3 is not intended or offered for sale (Section 7044, Business TOTAL 4: 00 and Professions Code). 'HE"KKe 1?j_ CONSTRUCTION LENDING AGENCY � - I hereby affirm that there is a construction lending agency for the CHANGE performance of the work for which this permit is issued (Sec. 3097, Civ. C.) ., c�%9 ill-��4£4=i i.�•.`'-'. `'_I Lender's Name N '4�C 511 L FII _:n.i_i 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 1; E s .WORKL'RS' COMPENSATION DECLARATION' nnn C n�+N FOR nB p nn'o NG PERWY 20-0026 DPW'4/87 G�1ll'Ir L� G�1 II�J IIS lr LL l�(fvu II�J l� n f'hereby,'affirmthat I•hove a.certificate of consent to self in-' 76A667A pure or a,ce,rtificate of Workers'Compensation Insurance,or'a CE 819(REV. 8/86) clprtified copy.thereof (Sec.3800; Lab.,CO.;r , PoT COUNTY OF LOS,ANG ELES DEPT. OF PUBLIC WC►RKS licy No. Company. 0 'Certified copy is hereby furnished' ` FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Cert,ified.copy`is:filed,with the countyk uilding inspectionADDRESS , NUMBER FIXTURE OR ITEM l` LOCALITY_ _ deparimenb @:. FEE ., Date } Applicant / WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' f" / BATHTUB CROSS 5T. COMPENSATION.INSURANCE OWNER 'T (This section'need,not'be completed if,fhe•'work involved by SHOWER, MAIL nn the permit:is for one hundred.dollars ($100)or less.) LAVATORY ADDRESS I_certify'that in tk6'pe&forrri6nce'of the work.for>which this per- mit is issued I shall not,employ any person in any manner so SINK : • CITYy ,TEL. NO as.to become'subject-to'the.Workers Compensation'Laws. _• DISHWASHER • I CONTRACTOR f�Lf/ / F :Date Appliccint " CLOTHES WASHER ADDRESS NOTICE TO APPLICANT; If, after making-.this Certificate of Ex- SWIMMING POOL RECEPTOR 'emption;you should become subject,to the Workers'Compeny sation.prov'isions of the Lobor Code,you must forthwith comp- LAWN,SPRINKLER SYSTEM CITY TEL. NO. ly with such provisions•orthis,permit shall be deemed.revok STATE UC. ed. WATER HEATER LICENSE NO, CLASS LICENSED CONTRACTORS.DECLARATION DISTRICT NO. OCESSED BY I hereby affirm that 1 am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9'(commencing with Section 7000)-of Division 3 of the Business OUTLETS OVER eif and Professions Code, and my.license is in.full force and ef- 5 PER SYSTEM 'FINAL feet. VALIDATION' .; .- License'Number' .. Lic. Class 0 O Contractor t ._ Dine O FINAL I am exempt under Seo. gy LU IL B.&P:C. for.ihis-reason Plan ch eck:fee - Date: . .. PLUMBING PERMIT ISSUING FEE$ OQ D Signature - TOTAL`FEE SINGLE FAMILY Plan check applicant I'herebyaff,irm Ihbt I ain exempt from the:Contractors License. Name HOME OWNER-BUILDER DECLARATIONt . Law for the following reason (Section 7031.5, Business andf Professions Code): Address " • 3301 0; 1,-as,owner of•the-property `will•do thework.ond the: City Tel. No. a structure is not intended or offered for sale(Section/044, NEMS Business-and Professions,Code).- f � . CONSTRUCTION LENDING—AGENCY.; I hereby affirm that there is a construction lending agency for -I�.°N3 Z.performance of tke,,work for which'this permit is issued ! 1- -= (Sec. 3097, Civ. C.). Lender's'Name fJ1I Lender's Address I certify that l have read-this,applicatiol i and state that the 50 123 j " 1) 7=13 above information is correct.,)agree to comply with all County D ordinances and State laws regulating Plumbing, and hereby Z.. authorise representatives-of.this County to-enter upon the above-mentioned property for,i ectio urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE r Signature of Permittee- Date