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Home My Public Portal About5036 KAUFFMAN AVE_Plumbing__ .WORKF,RS'COMPENSATION DECLARATION 7ea667w p I h•eretty affir'n that I have a- certificate.of consent to self cE'sn A(z-80) P P L I C A T�O N FOR P L U M B N G P E RM T insure,"or a tertsficate of Workers'Compensation Insurance,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'APPLIGANT TO FILL IN.(P.RINT OR TYPE) BUILDING ADDRESS Certified coIpy.is filed with.the county building inspection NUMBER" "FIXTURE OR ITEM' O FEE ' LOCALITY t department. WATER CLOSET _ �i Date Applicant BNEAREST ATH TUB CROSSST.' S�q � S a_ , CERTIFICATE OF EXEMPTION FROM WORKERS' - COMPENSATION INSURANCE SHOWER OWNER C LAVATORYMAIL (This section need not be completed if the work involved ADDRESS (O . &A } by .the permit is for one hundred dollars ($100) or less.) SINK a_ CITY `� TEL."NO. 0. I certify that`in the performance of the work for which this DISHWASHER `o dl ` <' /� 0 permit'is issued,'l shall not employ any,person in"anymanner CONTRACTOR P't Y` , 0: so as to become subject to the Workers' Compensation"Laws. CLOTHES WASHER /n - 0 ADDRESS �J Date Applicant 4 , U SWIMMING POOL RECEPTOR �f NOTICE TO APPLICANT:-If, after•making this Certificate of CITY TEL.NO. `G/ lL LAWN SPRINKLER SYSTEM d Exemption, you should become subject to the Workers' STATE LIC. U) Compensation provisions of the Labor Code, you must forth- LICENSE'NO CLASS with comply with, such provisions or this permit shall be WATER HEATER deemed revoked:, GAS SYSTEM OUTLETS DISTRICT NO. PROCESSED B LICENSED CONTRACTORS DECLARATION OUTLETS OVER - I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL , VALIDATION ness and Professions Code, and my license is injfull force and DATE effect. FINAL License Numb et� -�Lic:Class BY , I _ Date 7-aZn� Contractor a I am exempt'from the licensing-requirements as'l am a Plan Check fee licensed architect or'a registered professional `engineer t ' acting in my professional capacity (Section 7051, Bus- PLUMBING PERMIT ISSUING FEE$ iness and Professions Code). TOTAL.FEE. 00 1 3 6 1 A Lie.or Reg.No. Date Plan check applicant # o 0 0 o o J HOME OWNER-BUILDER DECLARATION Name e 2 o o:1.6'0 0 I hereby affirm that I -am exempt from the Contractor's Address- , o o 0 1 6.0 0:05 ' License Law for the following reason (Section.7031.5, Busi- City Tel.No. ness and Professions Code): --8 0 O1, as owner of the property,'am exclusively contracting with licensed contractors to construct the project (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 SEE-REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the. above-m oned property for inspection oses. . Z/:�a Signature of Per ttee Date WORKERS'COMPENSATION DECLARATION I.hereby, affirm that I have ci certificate of consent to self in- 76A666A PW 4/90 Qp "��C �®" " FOR PLU �� PRW �7 sure,or a certificate of Workers'Compe ation Insurance,ora n certified'copy tereof ( ec. 3 00, Lab. hull COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy Nc� Y'� any Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING. ide Certified copy is filed with the c un b 'I 'ng inspection ADDRESS CC// CJ �rtm ent. NUMBER FIXTURE,OR jTEM @ FEE LOCALITY Date Applicant WATER CLOSET(TOILET) NEAREST ' CERTIFICATE OF EXEMPTION FROM WORKBATH TUB CROSS ST, COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by, MAIL. the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- TE mit is issued, I shall hot employ any person in any manner soSINK CITY as to become subject to the Workers'Compensation Laws. DISHWASHER ` CONTRAC Date. Applicant qCLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certific'ote of Ex- ADDRESS em tion,you should become subject to the Workers'Com en SWIMMING POOL RECEPTOR P Y I P • ,CITY -TEL. J sation provisions of,.the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed-revok- STATE LIC. ed. WATER HEATER : LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION _ DISTRICT NO. PROCES BY GAS SYSTEM D OUTLETS m I hereby affirm that I.alicensed under provisions of Chapter Q 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,'and my license is in full force and ef- 5:PER SYSTEM FINAL 7VALIDATION fect. HOSCBIB DATE fp-�Zl—�7_ License Numb c. Class FINAL V Contractor Date BY ElI am exempt under Sec- Q _ U B.BP.C. for this reasonPlan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE SINGLE FAMILY _ HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name- s` 3 Wit..);.:-2 Law for the following reason (Section 7031.5, Business and ` Professions Code): Address 1,.as owner of the property, will,do the work and the City.,. Tel. No. rpm structure is not intended or offered for sale(Section 7044, Business and Professions Code). s(-k)}' 3 ECK CONSTRUCTION LENDING AGENCY H'-- I hereby affirm that there is a construction lending agency for { -CHAS,GE the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). 4 Lender's Name � - - - "' -" I AM 9-40 Lender's Address Icertify that I have read this application and,state that the above info r alio is correct. I agree to comply with all County ordinance and S to laws regulating Plumbing, and hereby author'z repr atives of this County to enter upon the above- ntio operty for inspect' purposes. 9 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date