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Home My Public Portal About6148 IVAR AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 26A(366DPW 9/89 APPLICATION PPL ICATION FOR PLUMBING, Ln nMBIN� PERMIT 11 . 7,6A667A /� J� u�l �J u�d �I IL11 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. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING n' F1 Certified copy is filed•with the county building inspection ADDRESS $ \V v Q. e department: I NUMBER FIXTURE OR ITEM @ FEE LOCALITY 72.vvt 1e ' Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. - COMPENSATION INSURANCE ASSESSOR ' MAP BOOK PAGE PARCEL (This section need not be completed if the work involved by'the SHOWER _ permit is for one hundred dollars($100)or less.) LAVATORY OWNER ;—CAA 1 I certify that in the performance of the work'for which this permit is issued, I shall not employ any person in any manner so as to SINK MAIL 2 ADDRESSCA, IC A VA 05 become subject to the Workers' Compensation Laws. "� DISWASHER CITY \ V, 4P,5 TEL.NO 7t�:i� '_ Date Applicant CLOTHES WASHER f NOTICE TO APPLICANT: If; after making this Certificate of CONTRACTOR Exemption;.you should become subject to the Workers' Compensation - SWIMMING POOL RECEPTOR , provisions of the Labor Code, you must forthwith comply with such ADDRESS 'i%� provisions or this.permit shall be deemed revoked. LAWN SPRINKLER SYSTEM. - LICENSED CONTRACTORS DECLARATION CITY < TEL.NO. '- WATER HEATER ��j �—• _ a I hereby affirm that I am licensed under provisions of Chapter 9 /v STATE _ LIC. / 0 (commencing with Section 7000) of Division 3 of the Business and LICENSE NO.. CLASS Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS (� OUTLETS OVER DISTRICT NO. PROCESSED BY - 5 PER SYSTEM �iD� ,✓ - 0 License Number Lic.Class (/ V ' - FINALl G •VALIDATION Contractor DateIL ❑ V @+�_•6 ova !A FINAL _z I am exempt under Sec. BY �4) B.&P.C.for this reason' - Plan check.fee I c - Dater Signature � 3 4`c i � ` PLUMBING PERMIT ISSUING FEE$ 41 Q '� - R;_ p ❑ ' _ --_ TOTAL FEE 1 17,j CHECK• ' �•�.v::-s Plan check. applicant (_-6 i(1�E SINGLE'FAMILY HOME OWNER-BUILDER DECLARATION Name' I hereby affirm that I am exempt from the Contractor's License Law ' r�3 ...i i s.. ` for the following reason (Section 7031.5, Business and Professions Address 1,�i.,,r_ :_,ILIA j Uj�, a:4 Code): i f ❑ City 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 1 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 representative of this County to enter upon the above-mentioned gro4Sia&of e for' s ectio urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ,iD--�2 9 ermittee Date WORKERS'COMPENSATION DECLARATION I hereby, affirm that I have a certificate of consentto se#'in- 20-0026 DPW 4/90 G�111' L5 Ili Il-L� Illv/U suYe,or a certificate of Workers'Compensation Insurance,ora 76A667A certified copy thereof.(Sec.3800, Lab.'.C.) COUNTY OF LOS.ANGELES DEPT. OF'PUBLIC WORKS Policy No. Company ❑ Certified copy is hereby furnished.. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING J Certified copy is filed with,the county building inspection ADDRESS NUMBER FIXTURE OR ITEM FEE LOCALITY department. @ G i Date Applicant ! WATER CLOSET(TOILET) ,10 NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB •CROSS ST. ' COMPENSATION INSURANCE OWNER r ,- SHOWER v (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.)' ,!LAVATORY. ADDRESSjl I certify that in'the performance of the work for which this'per- mit is issued,1 shall not employ any person in any manner so SINK CITY' TEL N0.2 \ �/ as to becorne u t to the Workers'Coin.pensation Lauwe - I J DISHWASHER ---.� -- CONTRACTOR � Date Applicant 'CLOTHES WASHER NOTICE TO APPLICANT:'If;.after a is,-rtificate of Ex ADDRESS em tion,you should become b'ect t the orkers'Com en- SWIMMING POOL RECEPTOR P y I P CITY TEL. NO. sation provisions of the Labo. +�rle,you ust forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit s all be deemed'revok- STATE LIC. ed. WATER HEATER LICENSE NO. . CLASS LICENSED,CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am Licensed under provisions of Chapter GAS SYSTEM OUTLETS, 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER, and Professions Code, and my license is in full force and ef- S.PER SYSTEM FINAL ' VALIDATION fect. HOSE•BIB DATE License Number Lic. Class- a. FINAL r�t,t Tas V Contractor Date BYAAA ', :?]03 1?3e90 O. I am exempt under Sec. f- B.&P.,C. for this reason 1 ITEMS U Plan check fee -123.90a Date:- T iTAL .�, PLUMBING PERMIT ISSUING FEE$ O -•o t-) Signature CHECK 123 9 .TOTAL FEE SINGLE FAMILY CHANGE -0 HOME OWNER-BUILDER DECLARATION' Plan check applicant. I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and. 0000-0001 5/ 2/96- Professions Code): Address 6170 1 Ate 10 a 00 I, as owner of the property, will do the work and the City TeL No. structure is not jntended 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-mention �p iy_f inspection purpo—s s. - 5 . _ SEE'REVERSE FOR EXPLANATORY LANGUAGE gna f e Date