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Home My Public Portal About6022-6028 KAUFFMAN AVE_Plumbing__ : 'RKERS'.COMPENSATION DECLARATION 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT ' I`hereby, 6ffirm that I have a certificate of consent to salf in- 76A667A sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) certified co t reof (Sec. 3800, Lab COUNTY OF LOS ANGELES DEPT. OF PUBLIC,WORKS, Policy No. Company Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN (PRINT OR TYPE) Certified copy is filed with the county building inspection ADDRESS Op� department. NUMBER FIXTURE OR ITEM @ FEE LOCALIT 0-Y0-1, WATER CLOSET(TOILET) Date Applica NEAREST J CERTIFICATE OF EXEMPTION FROM WORKERS' _ BATH TUB /� CROSS COMPENSATION INSURANCE / SHOWER OWNER (This section need not be completed if the )or less.) d by / MAIL the permit is for one hundred dollars ($100)or less.) � LAVATORY I o2 -� ADDRESS, 1 certify that in the performance of the work for'which this per- SINK �s CITY TEL. N�11_e6;5-1 mit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. DISHWASHER .... CONTRACTOR Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS��Q�j / SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY T N sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE q p p' LIC: ed. p WATER HEATER _ LICENSE NO. �/�p O CLAS �j�6 LICENSED CONTRACTORS DECLARATION / r DISTRICT NO. PR ESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS D s 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL ,. VALIDATIO fete. �/ &4 S//&� DATE License Nu b Lic. Class� � V 1D_ p� BY 0 Contractor Date �7 O 0 ❑ V I am exempt under Sec. � 6.&P.C. for this reason Plan check fee g Date: PLUMBING PERMIT ISSUING FEE$ Q Signature TTOTAL FEE 4 DD SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that 1 am exempt from the Contractor's License Name 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. structure is not intended or offered for sale(Section 7044, z 8 5 7 A Business and Professions Code). ® # 0 0 0 ,0,0 5 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for 0 o84.00 the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). 0 0 '0 8[( a 020: Lender's Name 1 21 4.-87 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 a ove-menti property for inspection purposes. /D-.30,f7 . SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT ��11 r t I.kereb�,'a 'Arm that I have a,certificate of consent to self in- 76A667A 'TUI sure,or,a certificate of Workers'Compensation Insurance,ora CE 817(REV. 8/86) certified c y there f (Sec. 3800, Lab. f COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No� / Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESSW4 , department. NUMBER FIXTURE OR ITEM Lal FEE // q LOCALITY , Date/�� i Applicant �' WATER CLOSET(TOILET) 4,0NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB Op CROSS COMPENSATION INSURANCE / SHOWER Op OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY /p�, OQ ADDRES 5 I certify that in the performance of the work forwhich this per- TEL SINK //7� A �f f mit is issued, I shall not employ any person in any manner so •40 CITY as to become subject to the Workers' Compensation Laws. / DISHWASHER 00 CONTRACTOR- Date Applicant - /. CLOTHES WASHER 00 NOTICE TO APPLICANT: If, a emtion, h 'fter making this Certificate of Ex- ADDRESS ��/ you should become subject to the WorkersCom en- SWIMMING POOL RECEPTOR P Y I P CITY : TEL. �l�� sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM I' ly with such provisions or this permit shall be deemed revok-. STATE �O�p p CLASS &/ 6-ed. WATER HEATER LICENSE NO. 7 O G LICENSED CONTRACTORS DECLARATIONJ DISTRICT NO APROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS + 9(commencing with Sectior 7000)of Division 3 of the Business OUTLETS OVER _ and Professions Code, and my license is in full force an/d_ef- 5 PER SYSTEM FINAL >r �- VALIDATI fete. j— ; d O 7 �! (3[� O DATE �--' License Numbe Lic. Class �j N rJ Contract -'151-1151-1-41�� Dat - B O I am exempt under Sec. B.&P.C. for this reason Plan check fee g Date: PLUMBING PERMIT ISSUING FEE $ D Q Signature TOTAL FEE �O SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and Professions Code): Address. F] I, as owner of the property, will do the work and the City Tel. No. structure is not intended or offered for sale(Section 7044, Business and Professions Code). Poo. S Jr &,5 A CONSTRUCTION LENDING AGENCY I'hereby affirm that there is a construction lending agency for # o 'o 0 0 o 5 the performance of the work for which this permit is issued (Sec. 3097, Civ. C.,)* ° ° 8 i, 0 0 Lender's Name o o o 8 1( Q ®5 Lender's Address 1 2.1 4 '8 7 I certify that I have read this application and state that the Poo.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 ab ve-mentio ro�erty�for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date yV�RKERS' CrJMPENSATION DECLARATION20-0026 1 PW 4/87 APPLICATION FOR PLUMBING PERMIT 1%bereGV affirm that I have o'certificate of consent to self in- 76A667A sure,o7'a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) certified co thereof (Sec. 3800, Lab, COUNTY OF LOS ANGELES Policy No� Company DEPT: OF PUBLIC WORKS � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the ounty building inspection ADDRESS " department. NUMBER FIXTURE OR ITEM @ FEE /�_� p' LOCALITY Date � O Applican , WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM-WORKERS' BATH TUB /� CROSS'S COMPENSATION INSURANCE / OWNER SHOWER. �. (This section need not be completed if the work involved by MAIL - the permit is for one hundred dollars ($100)or less.) LAVATORY of ADDRESS/ I certify that in the performance of the work for which this per- SINK 4 CITT� G�, TEL. mit is issued, I shall not employ any person in any monner so ""' as to become subject to the Workers' Compensation Laws., DISHWASHER CONTRACTOR .� Date Applicant / CLOTHES WASHER ��Q NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS �/_,7 emption,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR CITY �i TE sation'provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE Q/J p LIC. ed. / WATER HEATER LICENSE NO. �//�O CLASS LICENSED CONTRACTORS DECLARATION / GAS SYSTEM OUTLETS DISTRICT NO. P ESSED BY I hereby affirm that I am licensed under provisions of Chapter 0 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER fed Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINA r /' VALIDATI �//O�T �O DAT CS�� O License Nu ber Lic. Class/� •+ U r✓% Zd- FI L O Cor tracto Date • 0 0 I am exempt under Sec. B.&P.C. for this reason ' ► 8 Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Q v Signature TOTAL FEE d0 SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION pp I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and Professions Code): Address.• ❑ I, as owner of the property, will do the work and the City Tel. No. structure isnot intended or offered for sale(Section 7044, Business and Professions Code). 2858,bA CONSTRUCTION LENDING AGENCY # 0 0 0 0 0 5 1 hereby affirm that there is a construction lending agency for ' oro 8[�o O the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). o o 'o 8 Q, 0 d v Lender's Name ) 2, 1 4 -87 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 aut orize representatives of this County to enter upon the ab ve- enti property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date _. 'ORkER$' COMPENSATION DECLARATION 20-0026,DPW 4/87 APPLICATION FOR PLUMBING PERMIT 4 here�,`affirm,that I have 6 certificate of c6,isent-ro*elf in- 76A667A sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) certifiedy then f (S c. 3800, Lab. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy. N Compan Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING Certified copy is filed with the aunty building inspection ADDRESS. department. NUMBER FIXTURE OR ITEM �a FEE LOCALITY' / ? �i J _ WATER CLOSET(TOILET) Date/0-Ao O / Applicant NEAREST �j BATH TUB / CROSS CERTIFICATE OF EXEMPTION FROM WORKERS' a '^ COMPENSATION INSURANCE SHOWER / OWNER (This section need not be completed if the work involved by !O MAIL the permit is for one hundred dollars ($100)or less.) 2 LAVATORY ADDRES G I certify that-in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so �p — CITY L%� TEL.+ I�/'�c7S as to become subject to the Workers' Compensation Laws. ` DISHWASHER 40 ; / CONTRALTO op! Date Applicant / CLOTHES WASHER ADDRESS�� D NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,.you should become subject to the Workers'Compen- CITY sation provisions of the Labor Code, you must forthwith comp- ly with such provisions or this permit shall be deemed revok- STATE ? p p UC C, p a ed. WATER HEATER _ LICENSE-NO. 01 �CY O ASS LICENSED CONTRACTORS DECLARATION / D ICT NO ,� ROCESSED 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 / fect. and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION i DG'/ DATE License r4umbe 00 cf Lic. Class�� o FI V Contractor Date ' B O ❑ I am exempt under Sec. ' b3 B.BP.C. for this reason ► g Plan check fee Date: PLUMBING PERMIT ISSUING FEE $ O 8 5&8 A Signature TOTAL FEE OD SINGLE FAMILY # 0 0 0 0 0 5 HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name 1 ° -.84, 00 Law for the following reason (Section 7031.5, Business and Professions Code): Address o 0 0 8 IL Q 0_ U El I, as owner of the property, will.do the work and the City Tel. No. ) 2 1 4—8 7 structure is not intended or offered for sale(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 ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the abb -mentio operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Flermittee Date