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Home My Public Portal About5103 KAUFFMAN AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION /p1 MH PLUM PPUCA` FOR PL fiMG PERMT I hereby affirm that l have a certificate of consent to self 176A667A �' u u V ❑rfu insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified'-dopy thereof (Sec. 3800; Lab. C.) c- COUNTY OF LOS ANGELES. BUILDING AND SAFETY Paolicy'No��! 4 Com panytN,111-�o W tr/ Certified copy.is.hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ; w r Certified copy is filed with the county building inspec- ADDRESS r)/ 6 ,V tion department. _ NUMBER ' FIXTURE OR ITEM @ FEE LOCALITY P�l / 9-/(_g _ �� WATER CLOSET Date Applicant NEARESTIf CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER. OWNER (This section need not be completed if the work involved by MAIL 77 /" the permit is for one hundred dollars ($100)or less.)' LAVATORY3 ADDRESS Q ! I certify that in the performance of'the work for which this permit is issued, I shall not employ any person in any manner SINK CITY. ` TEL:NOVS- - e so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR �✓�/VU2- /C Re JPir y/fG Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT.: If, after making this Certificate of. Exemption, you should become subject to the .Workers' SWIMMING.POOLRECEPTOR ' CITYTEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM P�1t 4_ 7 with comply with such provisions or this permit shall be STATE LIC: deemed revoked. WATER HEATER LICENSE NO. 6 3 73 CLASS C . LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED BY I hereby affirm that I am licensed under provisions of,Chapter 9 GAS SYSTEM OUTLETS r (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full fgfc� �S and effect. 5 PER SYSTEM u41- oZ O DATE r" p VALIDATION A License Number 7,"73S Lic. Class SC yy t� d FINAL 601VA16OZ it/C lb / BY O Contractor Date � ��"., - �'� � ❑ V I,am'exempt under Sec. LU B.&P.C. for this reason Plan check fee (\ Date:, PLUMBING PERMIT ISSUING FEE'$ Signature TOTAL FEE Plan check,appl'icant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name a 3 5 G,3 A I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and o i jo 0 0 5 Professions Code): City Tel. No. ' I, as owner of the property, will do the work and the t , structure is not intended or offered for sale (Section 7044, Business and Professions Code). °'0 ° 1 650Z r. CONSTRUCTION LENDING AGENCY 'b�_8'4 I hereby affirm that there is a construction lending agency for t , 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 representatives of this County to enter upon the Xboventioned property for inspection purposes. 1� F SEE REVERSE FOR EXPLANATORY LANGUAGE Signatu of Permittee ��/ Date 1ORKERS COMPENSATION DECLARATION 2 AF.- 'n n n y� O n �pj n p!j PER n n :. _ 0-0026 DPW t/87 G�11T LL, A Il Ili IT L5 111V111 Il�u�/u erebyi,dffir,m:th6t I have;a certificate of consent to self in- •7tiA667A ��N NG �T O r'= sure or a certificate of Workers'Compensation Insurance,or a CE,817(REV. 8/86) certified-copy thereof (Sec. 3800, Lob. C.). I� �y Nom,., t COUNTY OF LOS ANGELES DEPT.'OF PUBLIC WORKS ,Policy No.''a21-4 Company '_5M7 Certified copy is.hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING . p Certified copy1s filed with the'county building inspection ADDRESS 103 ICA�FP�+ .A%/i�4 .,department'' E •@ .0 WATER CLOSET(TOIOLET)E LOCALITY /1L�','y f _ NUMBER M FEE f Ddte Applicant NEAREST �� G CERTIFICATE-OF EXEMPTION FROM ORKERS" BATHTUB CROSS ST LA-' - AOJAg .'' COMPENSATION INSURA CE OWNER, R f~ii�R-f',<.Sr.yAEF : SHOWER , (This section need not,be completed if the'work involved by MAIL _ the permit is for one hundred dollars'($100)'orless.) LAVATORY ADDRESS S�L �f' Pavv� I certify thoI in;the perfoemance of the work`for which^this per- hep 'SINK - - TEL. NO.a� mit,is'issued;'I'shall not employ any,person-in'any mannerso - .. CITY as to becorne`subj'ect'to the Workers'Compensation Laws. - DISHWASWER �.p - CONTRACTOR �y 4O6�LS At_Ao •'p Date r '•Applicant - . .CLOTHES.WASHER _ - - .. NOTICE TO APPLICANT: If; after'ntakmg;'this.Certifi'cateof`Ex= SWIMMI ADDRESS emption; you should become subject to the Workers'Compen- NG'POOL RECEPTOR A a!` , L G A'Ie• sation provisions of the Labor Code, you mustforthwiih comp- LAWN SPRINKLER SYSTEM CITY w� '�ovl�A'` TEL q�b-��rl /� �l NO ly with'such provisions or this.permit shall.be deemedrevok-_ d/ STATE ��p9 LIC. /{ ed: -WATER HEATER CLASS ' LICENSE NO. >Q J' , . / LICENSED CONTRACTORS DECLARATION' DISTRICT NO. PROCESSED BY I'hbreb affirm that I am licensed under pro Ivisions of Lha fer GAS SYSTEM OUTLETS 9=(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER fed Professions'Code,and my license is'in full force and ef- 5 PER SYSTEM FINAL ALIDATION' - DAT O License•Number � � Lic. Class O FIN// cc Contractor Date ' BY • O' ' I am exempt nder SecUJ '- B P'.C. f&r this reason U) n Pldn check fee, * Date: D PLUMBING PERMIT.ISSUING FEE'$ Signature . do TOTALFEE t SINGLE'FAMILY ! . HOME OWNER,BUILDER'DECLARATION Plan:check applicant I,Kerebyaffirm thatJtam exempt fro m.the•Cgntroctor's License Name taw-for,the following reosona(Section"7031;:5; Business'and Professions Code): Address ` F7 I, as owner'of`the'property; will do;the'work and the City Tel. No. , structure isnot intended or offered for:aale(Section.7,044; 1 v Business"and ProfessionsCode). "r CONSTRUCTION LENDING AGENCY' T hereby-affirm that there-is'a-construction lending ageneyfor ,j;jt It' -!n•__I the performance.of the work for which this permit is issued (Sec. 3097, Civ. C. ITEM, ; L'ender's Name: 3 i ril_. 3 _ 0 a Lender's Address. ,a, CHECK 34 e_10 I certify that I have read this application and state that the ` 4'k L'��1(z` e%1il above infarrciation is correct.-1 agree to comply with all County JAN ordinances and State laws,regulating Plumbing, and'hereby' r D authorize representatives of this County to enter upon the above-me ed prop ty for inspection purposes. 14 ;1-•i�i[41i'1 �i�lrr`ti tp � ' SEE-REVERSE FOR, EXPLANATORY LANGUAGE , �1`ijtC �Eler r Y Sign ure of Permittee' Dae