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Home My Public Portal About6247 KAUFFMAN AVE_Plumbing__ -: WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT " 1'J4ereb offirim'that I have'a certificate of consent to self in- 20-0026 DPW q/87 n Y- 76A667A sure, or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86). certilied.copy thereof (Sec. 3800, Lab. C.) Policy No \ (� ompany CAB i ha6 COUNTY OF LOS-ANGELES DEPT. OF PUBLIC WORKS Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ^` j �,_ Certified copy is filed with the cou y building inspection ADDRESS ��/ A, :W/ e t. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Ga .WATER CLOSET(TOILET).Date �/1 Applicant �� ^ « NEAREST CERTIFICATE OF EXEMPT! FROM WORKERS' BATH TUB CROSS ST. COMPENSATION SURAKCEn SHOWER h�!/t^C QF d�srOWNER / .S / r (�'�.4.�JS // /^� _ � . (This section need not be completed if the work involved by MAIL i n >:— the permit isJor one hundred dollars ($100)or less.) 'LAVATORY ADDRESS oE. No, azwtg � I-certify that in the performance of the work for which this per- mit is issued, I shall not employ an person in an manner so SINK CITY !+� v TEL. NO. P Y Y P _ Y �,l��j�j�•�� C�I C�� as to.become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR �.. I� Date Applicant CLOTHES WASHER n NOTICE TO APPLICANT: If, after making & this Certificate of Ex- ADDRESS �� .S'�°�iGf/t�-" SWIMMING POOL RECEPTOR emption, you'should become subject to the Workers'Compen,- f p/ CITY (�'-f ��rr TEL. NO.10, sation provisions of the Labor Code, you must forthwith comp- r LAWN SPRINKLER SYSTEM O 1 v�✓C• X57 ly'with such provisions or this permit shall be deemed revok- r STATE LIG ed" WATER HEATER LICENSE NO. ��G� CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY .1 hereby affirm that I am licensed under provisions.of Chapter GAS SYSTEM OUTLETS, n� 9(commencing with Section 7000)of Division 3 of the Business e OUTLETS OVER e fed Professions Code, and my license is in full force:and ef- 5 PER SYSTEM FINAL 2 �� VALIDATION C-�J DATE License Number Lic. Class GG- FINAL U Contractor /)11l�C r are / BY O 7 rY r-y I am exempt under Sec. LAJ f3.8P,C. for this reason Plan check,fee. ► Date: PLUMBING PERMIT ISSUING,FEE$ Signature TOTAL FEE. SINGLE FAMILY -- HOME OWNER-BUILDER DECLARATION Plan check applicant :fit-{ w5 ,:_;;1 I hereby affirm that I am exempt from the Contractor's License Name for the following reason (Section 7031:5, Business and- Law 1 f-"'-' Professions Code): Address. ^"Ig :Fa 50 E I, as owner'of the property, will do the work and the City Tel. No. j d'.ri 7,-,- structure is not intended or offered for sale(Section 7044, t Business and Professions Code). , i4 ShS=3— 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 ;_i31#_l(l Uli`s_'-s (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 Poo. ordinances and State laws,regulating Plumbing, and hereby a"uthorize'representatives of,this County-to enter upon the 660 enti ned pr �ert,for inspection purposes. �_ •,; �� (� �� SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Date `,VRKERS'COMPENSATION DECLARATION- 20-0026 DPW-4/87 APPLICATION FOR PLUMBING PERMIT " >Lhe eL�, affirm,that I have a certificate of consent to self in- 76A667A s're,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) certified copy thereof (Sec. 3800, lab. ) pony COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS � � . DCertified copy is hereby furnished. %-I—A03 FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection . ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE 9LOCALITY Date• ^/ Applicant WATER CLOSET (TOILET) A� Q NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER SHOWER - (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that,in the performance of the work for which this per- mit is issued, I shall.not.employ any person i'n any manner so SINK ` Z �,A CITY TEL. NO. ' as to become subject.to the Workers' Compensation,Law DISHWASHER a r1 CONTRACTOR Date � r ! � Applican� �� I CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If,'after making-this Certificate.of Ex- SWIMMING POOL RECEPTOR emption, you should become subject to the Workers'Compen- sationprovisions of the Labor Code, you must forthwith comp- . LAWN SPRINKLER SYSTEM �� " "(T� ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. j®Z CLASS G LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY I hereby affirm that I am licensed under provisions of.Chapter GAS SYSTEM OUTLETS 10 !J 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER o fe d-.Professions Code, and my license is in full force and ef- 5 PER SYSTEM �� FINA VALIDATION DATE �P License Number-15L.1-475" umber :� tic: OcIs' �. ,��✓ Qd FINAL g Contractor ate ` ' BY I am exempt under Sec. py B.BP.C. for this reason ► g Plan check fee Date: - PLUMBING PERMIT ISSUING FEE$ Signature .70TAC FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name Law forthe following reason (Section 7031.5,Business and os Professions'Code)' Address j,,as owner of the property, will do the work and the City Te 1. No. _ structure is not intended or offered for sale(Section 7044, '] Business grid Professions Code). _s --O 0 oo. _ .r- CONSTRUCTION LENDING AGENCY q.50 I hereby affirm that there is a construction lending agency for ••'HL^=``' the performance of the work.for which this permit is issued i= 1 _ t g (Sec. 3097, Civ: C.), -L Lender's Name Lender's Address i Ai e; I certify that'I have read this application and state that the oil.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 ignature o Permittee Date