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Home My Public Portal About5221 KAUFFMAN AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 7$A867A A-P P L I C A T I O N FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self ce e17 (z-eo) insure, or a certificate of Workers'Compensation Insurance,or a certified copy Q(thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NoT_S._1lZ�Company �(Z1f�� (_� Certified copy is hereby furnished. FOR APPLICANT'TO FILL IN (PRINT OR TYPE) BUILDING ,_/ - J ADDRESS � 2 Z 1 VA /<r,I�i Certified copy is filed with t county building inspection NUMBER FIXTURE OR ITEM • FEE• de rt t. LOCALITY WATER CLOSET Date , Applicant NEAREST CERTIFICATE OF EXEMPTION FROM W KERS' BATHTUB. CROSSS,T. COMPENSATION.INSURANCE SHOWER OWNER �) 1S7'1 MAIL (This section"need not be completed if the work involved' I LAVATORY ADDRESS !Ji 2.2 } V/cLk 'F�-t4 } Py the. permit is foi one hundred dollars ($100) or less.) SINK a CITY �� TEL.N�� 7$,� 0 I certify that in the performance of the work-for which this DISHWASHER t permit'is issued, I shall not emplo any person in any manner CONTRACTOR AL W�� ,�y• Y� � so as to bec me subject to the W ers' 0mpensation Laws. CLOTHES WASHER "0 ADDRESS ��332 f'A� 0 RA ,,20 Date Applicant SWIMMING'POOL RECEPTOR Y STN V NOTICE TO APPLICANT:-If, after making this C tificate of CITY• (:-4>"�YJ TEL. NO W Exemption, 'you should become 'subject to the Workers' LAWN SPRINKLER SYSTEMVJ Compensation provisions of the Labor Code, you must forth- STATE LIC. R z WATER HEATER LICENSE NO. �� .� CLAS �J with comply with such provisions or this permit shall be _ ,deemed revoked. . 9u; CT NO. CESSED BY GAS SYSTEM OUTLETS �j LICENSED CONTRACTORS DECLARATION OUTLETS OVER OB � t( f%� G 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 -/ VALIDAT N ness and Professions Code, and my license is in full force and DATE �� effect. 1 LFLLicense Num e Lic. Class `1 Contractor Date ,. Iam exempt from th licensing requirements as I am a Plan check fee licensed architect or a registered professional engineer jobacting"in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE O - d0 -Lic.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's Address 4 ';3 Z Q 8J License Law for the following reason (Section.7031.5, Busi- City Tel.No. 3 ness and Professions Code): ElI, as,owner of the property, am exclusively contracting 3 7A 1 A . with licensed contractors to construct the project (Section 7044, Business and Professions Code). # o-o o o o 5- CONSTRUCTION LENDING AGENCY 2 0 0 Q Q Q - I hereby affirm that there is a construction lending agency 'for the performance of the work for which this- permit is o 0 0 1 0.0 0= 'issued(Sec, 3097,Civ.C.). Lender's Name 0 1 1 4781 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 ` ' author' representatives of this County to.enter upon the above ntioned property for inspection purposes. Signature of Permittelle Dafte WORKERS'COMPENSATION DECLARATION a 76A887( ) , APPLICATIONP FOR PLUMBING P E R M I T I hereby affirm that I have certificate of consent to self cE ei7 i-eo � -• insure, or a certificate of Workers'Compensation Insurance,or ' a certified copy thereof(Sec. 3800,Lab.C.) COUNTY OF LOS,ANGELES BUILDING AND SAFETY Policy N rr�/ Y �� , Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ADDRESS ��, �•, � , Certified copy is filed with t cou ty building inspection NUMBER FIXTURE OR ITEM • FEE d ar t. Date AppLOCALITY, G WATER CLOSET licant I O NEAREST .� BATH TUB CROSS ST. - CERTIFICATE OF EXEMPTION FROM•W RKERS' 'COMPENSATION INSURANCE SHOWER OWNER IDC12U Ir LAVATORY MAIL /� } (This section 'need not be completed if the work involved ADDRESS 22 /� a. bythe permit is for,one hundred dollars ($100) or less.) SINKO CITY TEL. NQ U I certify that in the performance of'the work for which this DISHWASHER -At0 permit is issued, I shall not.'employ any person in any manner CONTRALTO so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER ` ADDRE3 3 1 jt�tU Date Applicant LLI SWIMMING POOL RECEPTOR CLNOTICE TO APPLICANT:-If, after making this Certificate of CITY TEL. t0 Exemption, you should become subject to' the Workers' LAWN SPR INKLE;R SYSTEM STATE (` LIC. Z Compensation provisions of the Labor Code, you must forth- LICENSE NO. �• 1 CLASS with comply with, such provisions or' this permit shall be WATER HEATER deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. P CESSED BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATION ness-and Professioris Code, and my license is in full force and- DATE �" effect. a FINAL License Num 'Lic.Class I BYG"'' Contractor Date F1I am,exempt from the rceirsing requirements as I am a Plan check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051, Bus= iness and Professions Code). TOTAL FEE Lic,or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's Address License Law for the following reason (Section 7031.5, Busi- City Tel.No. ness and Professions Code): I, as owner of the property, am exclusively contracting + with licensed contractors to construct the project3 3.3 3 A (Section 7044, Business and.Professions Code). CONSTRUCTION LENDING AGENCY # o'0 0 0 0 5 I hereby affirm that there is a construction lending agency 2 0 0 6 0 0 for the performance of the work for which this permit is ` ,issuedSec. 3097,Civ:C. . ( ) 0o0 � 6,005 Lender's Name . Lender's Address 1 208—.80 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 abov ntioned property for inspection purposes. f Signature of rer_rRqe bate