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Home My Public Portal About6032 KAUFFMAN AVE_Plumbing__ WORKt-RS'COMPENSATION DECLARATION 20-0026 DPW 4/90 APPLICATION FOR PLUMBING PERMIT I hereby,.%affirm;Ihut I hove a certificate of consent to self in- 76A667A supe,ora certificate of Workers'Compensation Insurance,or a certified-copy thereof (Sec. 3800, Lab. C.) Policy Np. Company S u COUNTY OF LOS ANGELES DEPToCIF PUBLIC WORKS Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ..� •�•—� ii Certified copy is filed with the county building inspection ADDRESS '. department. p/ NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date p Applicant' WATER CLOSET(TOILET) NEAREST �� CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. ��`� �j _ i 1 VYy� COMPENSATION INSURANCE SHOWER OWNER 1 �. (This section need not be completed if the work involved by MAIL ` �' 4 the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per SINK CITY ` TEL. NO.� mit is issued, I shall not employ any person in any manner so �''�"S t)lS 1(�(yy as to become subject to the Workers'Compensation Laws. DISHWASHER y1 CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen.- CITYC (� C TEL. NO. sation provisions of the Labor Code, you }must forthwith comp- LAWN SPRINKLER SYSTEMS o ly with such provisions or this permit shall be deemed revok- STATE to LIC. ed. WATER HEATER LICENSE NO. ( CLASS :2% LICENSED CONTRACTORS.DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM �� FINAL/0— y VALIDATION fect. fHOSE BIB' DATE /O—��—�/ License Number :A t'©L� Lic. Class t. FINAL` /%� (�j , 4Z. 1 Contractor �" Date J BY ❑ I am exempt under Sec. / V B.&P.C. for this reason Plan check fee ► Date: PLUMBING PERMIT ISSUING FEE$ Signature _ �- D SINGLE FAMILY TOTAL FEE ' 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 — - -- 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). T- y •^,- 0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for - 5= the performance of the work for which this permit is issuedsjs�.�` , E (Sec..3097, Civ. C.). Lender's Name ✓� i�r"Gy 1 9 !_s`,,: Si.l,f il A Lender's Address f Z =f=4 r 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 above-ment' ed pro rty r inspection purposes. --7-73—•.7-23 SEE REVERSE FOR,EXPLANATORY LANGUAGE Signature of Permittee Date