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Home My Public Portal About10206 LA ROSA DR_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION w TION COR- PL' 1,aBIN PERMIT I hereby,affirm that I have a certificate of consent to self in- 20-0026 60AA66 A PW 4190. Mr r M 1, r V m V PERMIT Fure,or a certificate of Workers'Compensation Insurance,or a - n certified copy thereof(Sec. 3800, Lob:C.) - 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 ADDRESS �Qpv7p department. NUMBER. FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET(TOILET)• NEAREST , CERTIFICATE OF EXEMPTION FROM WORKERS' -- BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER d SHOWER PiUG'l6 /L/�R" 1'djL/ (This section need not be completed if the work involved by MAIL the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK - ' mit is issued, I shall not employ any person in any manner so CITY TEL. NO. as to become subjectto the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, offer making this Certificate of Ex- ADDRESS emption, you should become subject to the Workers'Compen. SWIMMING POOL RECEPTOR sation provisions of the Labor Code, yournust forthwith comp- LAWN SPRINKLER SYSTEMS CITY TEL.NO. ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION .. _- / DISTRICT NO. PROCESSED BY I hereby affirm that Com licensed under provisions of Chapter GAS SYSTEM OUTLETS 16 4DATE�J—� D� 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM AVALIDATION fecL HOSE BIB .Z T License Number Lic. Class d FINAL O Contractor Date _ BY 5V 4ztCC . .:. t O ❑ I am exempt under Sec. - - t~.7 H�.i.T. B.BP.C..for this reason 3303 59.SG m Plan check fee Boo. Is Date: ' PLUMBING PERMIT ISSUING FEE$ I ITEMS i Signature TOTAL FEE- O TOTAL 59 . 50 SINGLE FAMILY - CHECK 59.i HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exemptfromthe Contractor's License Name . CHAt'<UE' '('C: Low 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.- GGGG-0-00 1f 1 77 structure is not intended or offered for saleSection 7044: �_ 'Business and Professions Code). ( L 1717 1 FSM 5:1-+ CONSTRUCTION LENDING AGENCY I hereby affirm that there is o 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 poll information is correct. I agree to comply with all County ordinances and St to laws regulating Plumbing, and hereby authorize repres tafives of this Cou my'to enter upon the 04--k-entiono property for inspection pur— SEE REVERSE FOR EXPLANATORY LANGUAGE ig azure of ermitiee Date WORKERS'COMPENSATION DECLARATION - APPLICATION FOR PLUMBING PERMIT by affirm that I' have a certificate of consent to self 76AM7A or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) _ertified copy thereof (Sec.,3800, Lab, C.) COUNTY OF LOS ANGELES T BUILDING AND SAFETY olicy No. Company - - Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ❑ ADDRESS Certified copy is filed with the county building inspec- _ - V tion deportment. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. j. COMPENSATION INSURANCE SHOWER OWNER tilL (This section need not be completed if the work involved by , the permit is for one,hundred dollars ($100)or less:) MAIL LAVATORY t ADDRESS I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner SINK CITY ) t TEL. NO 7- 16 0 7 so as to became subject to the Workers Compensation Laws. DISHWASHER `' G 6-7_-'R_3 ` �I1( 1 CONTRACTOR •� Date Applicant�V�• C• AIL•ASO 1� CLOTHES'WASHER NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS • ll Z Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY ` TEL. N LAWN SPRINKLER SYSTEM . ,2Z6 with comply with such provisions. or this permit shall be STATE t LIC. 2 / deemed revoked. WATER HEATER LICENSE NO. Z-) CIASS �'-•3 6 LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCESSED,BY I hereby affirm that I am licensed under provisions.of Chapter GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 o the Business OUTLETS OVER and Professions Code,and my license is in full force and effect - 5 PER SYSTEM �— FINAL / VALIDATION V 9g 7 Lic. Class FIAO License Number cc FINAL n 0 Controctor-l"n FCL•'1\CA Date( BY VJ--+�f V W ❑ d a I am exempt under Sec. » B.&P.C. for this reason DoZ . Plan check fee , f `!O � _ jo (O 7 Signature PLUMBING PERMIT ISSUING FEE$ !) -[ LL//RR LfQh�-. TOTAL FEE s-6 Plan check applicant 22 Q 6.0 A SINGLE FAMILY - HOME OWNER-BUILDER DECLARATION Name 1 hereby affirm that l am exempt from the Contractor's License Address, Law for.the following reason (Section 7031.5, Business and _ Z ° - 30,5 Professions Cade):' City Tel. No. - ' ❑ I, as owner of the property, will do Ike work and the 1° °�t J Q'5 0 o structure is not intended or offeredfor sale (Section Poo - o'6152-83 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 011. - _ above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing,and hereby t. authorize representatives of this County to enter upon the above-mentioned �Ierty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE C1s1v ' CJ�� t1 Signature p ermittee Date