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Home My Public Portal About6122 IVAR AVE_Plumbing__ WORI,rZS' COMPENSATION DECLARATION A P P U CAM N U O W P L V MM u V IG PERMT Wnerebyy3jfirm tha: I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers' Compensation Insurance, 76A667A or'd certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS- P❑olicy No. Company Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING --j{ J Certified copy is filed with the county building inspec- ADDRESS v'c tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET Sv NEAREST CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB COMPENSATION INSURANCE SHOWER OWNER �_ "44-.S �Ul+� _ / (This,section need not be completed if the work involved by MAIL . the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS 5 1_- , G457'0NJ'4-S 44P-- I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY �� ) TEL. NO. o'Z�/a so as to become subject to the War ensation Laws. DISHWASHER ,v CONTRACTOR Date Applica 242A CLOTHES WASHER ADDRESS NOTICE TO APPLIC NT: If, after maung this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL. NO. Compensation provisions of the Labor Code, you must-forth- LAWN SPRINKLER SYSTEM with: comply with such provisions or this permit shall be STATE LIC. deemed revoked. f WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCESSED BY I hereby affirm that I,am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETSU'Cl (commencing with Section 7000) of Division 3 of the Business' OUTLETS OVER U }}. and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION rZ DATE U License Number Lic. Class -2b�93 . FINAL Contractor Date BY ❑ ®) I am exempt under Sec. W, B.BP.C. for this reason W Plan check fee CO Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEEig '00n Plan check applicant SINGLE FAMILY 5.'t/� y HOME OWNER-BUILDER DECLARATION Name A4C1 ov I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and . J3�� ° Professions Code): City Tel. No. 50 I, as owner of the property, will do the work and the 1.JTEi'S,-_.. structure is not intended or offered for sale (Section " 7044, Business and Professions Code). TOTAL. 410.50 CONSTRUCTION LENDING AGENCY CHECK 40°511 1 hereby affirm that there is a construction lending agency for O� the performance of the work for which this permit is issued CHANE ° (Sec. 3097, Civ. C.).' +y / a Lender's Name OOCiO-0001 8/281V7 Lender's Address c-44 1 PM12S05 I certify that I have read this application and state that the D above information is correct. I agree to comply with all County or ' ce an State laws regulating Plumbing, and hereby duthorjo r r sentatives of this County to enter upon the a m do a 'property r inspection pu le SEE REVERSE FOR EXPLANATORY LANGUAGE re of Permittee Date WORKER'S COMPENSATION DECLARATION 720-0026 6A667A PW 9/89 APFUC ATT .O'� FOR PLUM IG PERMT I hereby affirm,jhat 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. ❑ FOR'APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING _ Certified co is filed with the count building ADDRESS Z copy y g inspection department. . NUMBER FIXTURE OR ITEM @ FEE LOCALITYIA C� Date APplicant / WATER CLOSET NEAREST / CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB ` CROSS ST.IL _ COMPENSATION INSURANCE ASSESSOR f� �j SHOWER MAP BOOK ��f PAGE�r!/ PAflCEIv/ ' (This section need not be completed if the work involved by the , permit is for one hundred dollars($100)or less.) OWNER LAVATORY I certify that in the performance of the work for which this permit / .�� , is issued, I shall not employ any person in any manner so as to SINK MAIL t ADDRESS PR- become subject to the Workers'Compensation Laws. C DISWASHER CITY /� ,, TEL.NO.'LDS_ 61 Date Applicant CLOTHES WASHER �l - NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION � CITY TEL.N0. 1' I hereby z�/affirm that I am licensed under provisions of Chapter 9 WATER HEATER l t1 (commencing with Section 7000) of Division 3 of the Business and STATE LIC. 0 Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS 0 OUTLETS OVER DISTRICT NO. PROCESSED BY f= 5 PER SYSTEML4� �dl/ Q License Number � Lic.Class (v/ L FINAL VA.LI—r---BION a DATE �Z _ , Contractor Date 1 am exempt under Sec. BY AL B.&P.C.for this reason Plan-check fee iji (s_ rx1�Ys Date: Signature PLUMBING PERMIT ISSUING FEE$ � ® _-,'(_}`•., �__..4%, TOTAL FEE SINGLE FAMILY Plan check applicant -HOME OWNER-BUILDER DECLARATION -Name - _�`••��i—t i;��.>_ __. �.�... +'f• I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address Co 1 City Tel.No. I,as owner of the property,will do the work and the structure / r is not intended or offered for sale (Section 7044, Business ..,• I - and Professions Code). CONSTRUCTION LENDING AGENCY mow• 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 D 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 proper ,te ection purpo s. SEE REVERSE FOR EXPLANATORY LANGUAGE )gnature of Permittee Date WORKER',$COMPENSATION DECLARATION 20-0026 DPW 9/89 �p � �p np p ��7 I hereby affirm that I have a certificate of consent to self insure, 76A667A QPIT'L��C/i-rl�� N FOR If'I�lJI1N5tl p NG p°ERMT or accertificate of.Worker's Compensation Insurance, or a certified cgpy 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 FOR APPLICANT TO FILL IN(PRINT,,OR TYPE) ADDRESS Certified copy is filed with the cou buil spe department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date YApplicant WATER CLOSET NEAREp CERTIFICATE OF EXEMPT N FR M ORKERS CSTROSS ST. BATH TUB o V (� COMPENSATI INSU CE IIASSESSOR (This section need not be c plated if the work involved by the SHOWER MAP BOOK PAGE PARCEL permit is for one hundred ollars($100)or less.) OWNER OM I certify that in the performance of the work for which this permit LAVATORY OWNER is issued, I shall not employ any person in any-manner so as to MAIL SINK ADDRESS become subject to the Workers'Compensation Laws. DISWASHER CITY T TEL.NO. 1 Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Il- _ n Exemption, you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS, 16so S M provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM , / LICENSED CONTRACTORS DECLARATION CITY o''1�yz�V TEL. O. S3�/ } I hereby affirm that I am licensed under provisions of Chapter 9 STATEWATER HEATER �// Q�^� J O (commencing with Section 7000) of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. •Z� V LZ� CLASS V Professions Code,and my license is in full force and effect. / - DISTRICT NO. PROCESSED BY OUTLETS OVER IM 5 PER SYSTEM Sys O License Number Lia Class FINAL L DATE -7, ''7 �j /�VALIDATI a Contractor Date / Vit'`- °3 (n ❑XB.&P.C. emVhis rSec. BY FINAL foason 1 %M`__ Plan check fee Date: I(_3 b'a_ U 9 Fe PLUMBING PERMIT ISSUING FEE$ _ Signature ;'HE-IC {e TOTAL FEEEl Plan check applicant SINGLE FAMILY 1 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): ' F] 1, as owner of the property,will do the work and the structure T . No. 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 corr . I agree to comply with all County ordinances and State I s re Plumbing, and hereby authorize represen ves o is o y me upon the above-mentioned prop. for i ction ur S. SEE REVERSE FOR EXPLANATORY LANGUAGE I 6 / S' O ature of P mittee Date