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Home My Public Portal About10403 LA ROSA DR_Plumbing__ DEC TION WORKERS*t I have a certificate cafe of corse APPLICATION FOR. PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE Bl](REV. 10/81) �Q-l/Feerrtified copy thereof Sec. 3800, Lob. C..)) /� COUNTY OF LOS ANGELES BUILDING AND SAFETY rcy NoO�"'O5� 7C i pony �.�JAU_SgLA� ,^ Certified copy is hereby furnished. !�(J G /a �. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUADDRILDING (� Certified copy is filed with the count building inspec- ESS lion departmenI. NUMBER FIXTURE OR ITEM R FEE Q/J LOCALITY Date '�7 Applicant WATER CLOSETDoNEAREST CERTIFICATE OF EXEMPTIOROM WORKERS' BATH TUB D CROSS ST. COMPENSATION RANCE SHOWER ry/� OWNER JKAi (This section need not be compia d if the work involved by W MAIL the permit is for one hundred dollars ($100) or less.) LAVATORY oQ ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINKCITY fq4g TEL. NO. so as to become subject to the Workers,Compensation Laws. ' DISHWASHER CONTRI to ACTOR ROA 11 10 Date Applicant ' CLOTHES WASHER 00 NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS I /Go er. Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY / D TEL NO. BOJ with comply with such provisions or this permit shall be STATE /J L LIC, fJ deemed revoked. WATER HEATER LICENSE NO. J CLASS C LICENSED CONTRACTORS DECLARATION D DISTRICT NO. P CESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS rl (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER y - =fir } and Professions Code, and my license is in full force and effect. 5 PER SVSTEM s •.J FINAL -�O VALIDATION a I � ",�1 "� V License Number. 0O Lic Closs��r2 DATE ' aG FINAL Contractor Date 6dy.o)�j�— BY �` U ❑ W Iexempt under Sec. w Bdc. for this reason z Plan check fee Poo.Date: PLUMBING PERMIT ISSUING FEE$ io Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name r 2 7 9.7 A I hereby affirm that I am exempt from the Contractor's License 1 Law for the followAddress ... o ..• rj following reason (Section 7031.5, Business and Professions Code): City Tel. No. 2 a e 7 a �]I 5 ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section , _ 0 - I 7 a`2T r v 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 06 15'-83 1 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 ab ve- ntioned pr p rte for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 119 -lure of Permittee Date wtJRKERS"COMPENSATION DECLARATION � APPLICATION FOR PLUMBING PERMIT {� firm that I have in certificate of consent to self 76A667A I J nsure, or a certificate of Workers' Compensation Insurance, CE 817(REV, 10/81) L or,p certified copy thereof (Sec 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY P❑olic'y,No. Company ^ C.rtified copy is hereby furnished. ❑ . BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) Certified copy is filed with the county building inspe<-. ADDRESS 0 tion department. NUMBER FIXTURE OR ITEM Cay FEE LOCALITY Date Applicant WATER CLOSET� NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH ruB CROSS ST. COMPENSATION INSURANCE OWNER SHOWER (Tela section need not be completed if the work involved by MAIL D r the permit t for one hundred dollars oor lessLAVATORY 1..� I certify that in the performance of thee work k for which ch this ADDRESS permit is issued, I shall not employ any person in any manner SINK Old CITY so as to become subject to the Worker 'Compete ation Laws. DISHWASHER ��(( x�''77 � CONTRACTOR Daley 7Applicont CLOTHES WASHER NOTICE TO APPLICANT: If, after aking this Certificate of ADDRESS Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITYT NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE C. deemed revoked. WATER HEATER LICENSE NO. ' S LICENSED CONTRACTORS DECLARATION DISTRICT NOb I hereby affirm that 1 am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER t and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FFIIAN EL &2 � VALI TION Orl7 License Number tic Class 0 FINALC Contractor Date BY ❑ 0 am exempt under Sec. 0 U 8.8P.C. for this reason W Plan check fee ► D..' Date: Z PLUMBING PERMIT ISSUING FEE$ Z_ Signature ;26459A TOTAL FEE Plan check applicant SINGLE FAMILY p HOME OWNER-BUILDER DECLARATION Name e e 4 a-TO I hereby affirm that I am exempt from the Contractor's License Address 0 2 Q 2±87 Law for the following reason (Section 7031.5, Business and Profess ions Code): City Tel. No. LJ 1, as owner of the property, will do the work and the 011,structure is not intended or offered for sale (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby offirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Ci, 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 lows regulating Plumbing, and hereby authorize represe tiv sof this County to enter upon the above-mention rop ty for - pection purposes. t SEE REVERSE FOR EXPLANATORY LANGUAGE 3Q . Signature of ermittee Date