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Home My Public Portal About6262 IVAR AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION /p�pp��CAp UMH FOR PL inn a MG FIERMP� -1:1hereby affirm that f have a certificate of consent to self' 76A667A �. insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. IWBt) or a certified copy thereof (Sec. 3800, Lab. C.) 'COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ADDRESS G X/ -L b,,- =Certified copy is filed with the county building inspec- tiondepartment. NUMBER FIXTURE `. .' @ FEE LOCALITY J WATER CLOSET /?�� Date Applicant -� NEAREST F� / TU&, CROSS ST. BATH CERTIFICATE OF EXEMPTION FOOM WORKERS' �/ COMPENSATION INSURANCE OWNER / (This section need not be completed if the work involved by SHOWER ,(L/O'y�I L LAS the permit is for one hundred dollars ($100)or less.) LAVATORY �� ADDRESS �� !�/' MA 1 certify that in the performance of the work for which this , / �— -v` permit is issued, I shall not employ any person in any SINK CITY TEL. NO.manner � DLLs c� 0 so as to become subject to the �o'r ers Compensation Laws. DISHWASHER t v'9 CONTRACTOR Date v Applican CLOTHES WASHER' ADDRESS NOTICE TO APPLICANT: 'If, aft mJing 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 .r with comply with such provisions or.this permit shall be STATE LIC. deemed revoked. WATER.HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICCLNO. P SED 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 ✓ (•P and Professions Code, and my license isin full force and effect. 5 PER SYSTEM FINAL \/ACID TION - DATE ( � License Number Lic. Class } e @� FINAL 1 ,� Contractor -Date BY �J ea aI am exempt under Sec. C 2 8 7.5 A B.&P:C. for this reason (� Plan check fee �". . . -. �� A10 0 0;o o•5 Date: PLUMBING PERMIT ISSUING FEE ( 0.o-52-50 Signature f TOTAL FEES2 \ 0 0 05250 Plan check applicant- �� SINGLE FAMILY' � Q 9,0 9-8"5 HOME OWNER-BUILDER DECLARATION Name �/P I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and Address c,(„*/�' \ \ .ProfAssions Code): City' C Tel. No. I, as owner of the property, will do the work_and the / structure'is not intended or offered for sale (Section D 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'sAddress 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 repre entotives of this County toe ter upon the abo e- noon ope ty.for in pection purp es. SEE REVERSE FOR EXPLANATORY LANGUAGE ' gnatur of Permittee Date , KERS' COMPENSATION DECLARATION"' n n n p CAA M N 20 n P p I e ;!affirm that Vhave a certificate of consent to self in 20-0026 DPW,4/Br G�1lr l!"L� IIV IT IIS L�IJuVvu • ,76A667A„ • sure,or a certificate of Workers'Compensation Insurance,ora CE 817(REV:8/86)' certified-,copy thereof (Sec. 3800, Lab C ). ,'f PolicyNo. Company. - COUNTY 'OF,LOS:ANGELES DEPT 0F.PUBLI_C WORKS Certified copy is hereby furnished ' .� .. IN FOR APPLICANT TO FILL IN (PRINT.OR TYPE)- 'BUILDING ;r . Certified'copy is'filed•with the county l5bilding'inspection ADDRESS `: )�V { / '-� department. t @ LOCALITY - NUMBER FIXTURE.OR ITEM FEE WATER;CLOSET(TOILET) Date Applicant �' NEAREST CERTIFICATE OF EXEMPTION FROM'-,WORKERS' CROSS y, ' `• BATHTUB YJ L \ CT COMPENSATION INSURANCE OWNERST SHOWER. Gr Imo/ �LSQ+�/ the permit is for•one hundred dollars $Ip Work mgolved.by MAIL This section need not be com leted if the + :y p ( 0)or less.) LAVATORY 3 ADDRESS I certify that in the performance of the work for'which this per' - SINK O� mit is-issued, I shall not employ any pe son in any manner so NCITY .3 �ZL6'Il " TEL NO �/7 as to become S.Y.b'ec to the'Workers ns'ti �Laws / DISHWASHER _ (JA�p}V� ►1p[ _ CONTRACTOR. �h✓�t(�� Date *�v "Applicant V CLOTHES WASHER NOTICE TO'APPL'ICANT:'If, after ma&g:this Certificate•of Ex- ADDRESS erription,you.should become subject to the Workers'=Compen-. "'. CITY .`,'TEL. NO.- SWIMMING'POOL RECEPTOR' sation provisions of-the Labor Code,,you must forthwith comp= LAWN SPRINKLER SYSTEM ly"with such provisions'or this permit shall be deemed revok- e: STATE OC. ' ed.., �. WATER HEATER LICENSE NO. CLASS . r I LICENSED CONTRACTORS:DECLARATION{. DISTRICT.NO.. PRO ED BY 00 GAS SYSTEM OUTLETS Hereby affirm that I-.am licensed under provisions of Chapter ,,9(commencing with'Section 7000)of-Division 3 of the''Business OUTLETS OVER and Professions Code and tmy license ism full force'ond-ef- 5-PER SYSTEM FINAL VALID ION fect a• DATE C License Number Lic Class l'f nom V FINAL . } Contractor Date" BY `, _ O, I'-am exempf under Sec 01 B'.&P:C: for this reason' 1`V Plan check fee 2 9 2 9.5 ... -. , ... ,_ Date:;• '. c, PLUMBING PERMIT ISSUING EEE$' # o, 0-0 5 D r ,� g } .Signature _ . w. .,. SINGLE•FAMILY Plan TOTAL FEE Q &00 HOMEOWNER-BUILDER DECLARATION check appliconf r �`� a00� .1 hereby'affirm that 1'am exempt from the'Contractor's License Name Law for, the following.reason (Section,7031.5; Business and 0'(I 0 `8 Professions Code): ,Address I.ais owner'.of the property; `will do the wo,k;and the ' City Tel. No: , st ucture'is not intended'or offered for sale(Section 7044, Business and Professions Code). ' CONSTRUCTION LENDING AGENCY D 1 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 Lend'er's Address. I 'certify that I have read this application and state that the abve.information is correct. I agree to comply with all County D ordinances and State laws regulating Plumbing, and hereby autho i e represen ti es of this County to enter upon the abav - enlioned ro erty or inspection purposes. (� 3SEE:REVERSE.FOR EXPLANATORY LANGUAGE i na ure of Permittee Date