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Home My Public Portal About6014 KAUFFMAN AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby, affirm that I have,a certificate of consent to self in- 76A667 76A667A DPW.4/87 sure,or a<erSficate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) ceftified'copy thereof (Sec. 3800, Lab./C. Policy.No !I myCL�JGSCw�sF COUNTY OF LOS ANGELES DEPT. OF.PUBLIC WORKS ❑ Certified co3 py is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ....�- Certified copy is filed with the coun u' i ns c' n NUMBER FIXTURE OR ITEM FEE ADDRESS •department. Date &SAY,?! Applic @ WATER CLOSET(TOILET) •� �� NEAREST a CEFICATE OF EXEMPTION FRO ORKERS' BATH TUB CROSS ST. R I 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 J/ �� ADDRESS I certify that in the performance of the work for which this per- 42 SINK / mit is issued, I shall not employ any person in any manner so CITY• !�D TEL. N as to become subject to the Workers' Compensation Laws. / DISHWASHER CONTRACTOR Date 'Applicant CLOTHES WASHER �v NOTICE'TO APPLICANT:.If, after making this Certificate of•Ex- ADDRESS emptiori, you should become subject to the Workers'Compen SWIMMING POOL RECEPTOR, CITY TEL. NOvl--7�� sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM- c << ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS L. 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 fand e Professions Code, and my license is in full force and ef- 5 PER SYSTEM. FINAL VALIDATION DATE License Number sLic. Class (� FINAL c g Contractor`Z'y6 Dote ACCT. I am exempt under Sec. B.BP.C. for this reason Plan check fee s� l/ 3307' 25�4� ��U) Date: �� A ITEMSV � PLUMBING PERMIT ISSUING FEE $ Signature �D TI_ITAL 250 ® 65 TOTAL FEE i� SINGLE FAMILY CHUCK _Ei�a1=•.t HOME OWNER-BUILDER DECLARATION Plan check applicant _ I hereby affirm that I am exempt from the Contractor's License Name CHANGE Low for the following reason (Section 7031.5, Business and ' Professions Code): Address _ 30011-•.1131. 2. •5 a ❑ Cit Tel. No. 1 ' I, as owner of the property, will do the work and the Y _ ._ ...........__ ' C- 'j structure is not intended or offered for sale,(Section 7044, �rlt1_t j {� � i'�i 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.). I Lender's Name .Lender's Address I certify that I have read this plication and state that the above information is co agree to comply with all County ► ordinances and St la legulatin Plumbing, and hereby authorize a'tiv of t unty to enter upon the abov a ed or er spection �4* 9 SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ature of Pefmittee Dat ION WORKER'S have a cNSATate of consent 76A666DPW9/89 APPLICATION FOR PLUMBING PERMIT ll r - 76A667A I hereby affirm,that I have a c8rtificate of consent to self insure, or a Certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab. C.) �fJ- 7T^_T� Pu AJ p COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No. Company �e, ❑ I - 4;, ti ,> Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with theiiR� pection ADDRESS r✓ yq(� F��I(i department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY lei 6 Date Applicant WATER CLOSET NEAREST n j/ C TIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. ®O (�r— (Gi ,! y(�� , COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) OWNER W LAVATORY 1 certify that in the performance of the work for which this permit MAIL is issued, I shall not employ any person in any manner so as to SINK ADDRESS become subject to the Workers'Compensation Laws. �� Z DISWASHER CITY i / TEL.NO. G Date Applicant' CLOTHES WASHER L !r O NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY C„-_ M&jVto TEL.NO �� 0 p a I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER WN�V 0- (commencing with Section 7000 of Division 3 of the Business and STATE LIC. T O ( 9 ) LICENSE NO. CLASS W (� Professions Code, and my license is in full force and effect. f &44GAS SYSTEM OUTLETS Q OUTLETS TPER OVER DISTRICT NO/� �i PROCESSED BY O License Number Lic.Class+,`0 0 f C i FINAL TION W VALIDA rsn!' �� Date DATE y�f ,/J a Contractor� � _� (n EJ FINAL Z I am exempt under Sec. BY B.&P.C.for this reason Plan check fee ate: - PLUMBING PERMIT ISSUING FEE$ " Signature EJTOTAL FEE SINGLE FAMILY Plan check applicant _. Atcl,s --•- ` HOME OWNER-BUILDER DECLARATION Name til { 4:o _r I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address 1 ITEMS Code): El 1, Tel.No. _ TOTAL 1,as owner of the property,will do the work and the structure y iEITryL is not intended or offered for sale (Section 7044, Business CHECK 40,6 and Professions Code). -HANE e.� LU CONSTRUCTION LENDING AGENCY 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.) 0000-0001 3/30/93 8935 1. AN 8 4 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-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date