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Home My Public Portal About9931 LA ROSA DR_Plumbing__ WORKERS'at I have a ION DECLARATIONofconsent "w"" APPLICATION FOR PLUMBING PERMIT: /7 I hereby affirm that I have a' certificate at consent to self ce an Iz-eol y 1 insure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800, ab C. COUNTY OF LOS ANGELES BUILDING YAND SAFETY Policy No. Company '��. ` �P ( ue G. Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING , [� _ NUMBER FIXTURE OR ITEM • FEE ADDRESS 3� K Certified copy is filed with �unt b ilding inspection LOCALITY ^��'�(� Y}' de ar men WATER CLOSET 6'• Date �r�?/Applican NEAREST BATH TUR CROSSST. J CERTIFICATE OF EXEMPTI N FROM WORKERS' ' COMPENSATION INSURANCE SHOWER OWNER TORY MAIL LAVATORY r� j. (This section need not be completed it the work involved LADDRESS 3 Q CL by the permit is for one hundred dollars ($100) or less.) SINK CITY TEL.NO.�� I U I certify that in the performance of the work for which this DISHWASHER I u CONTRACTOR permit is issued, i shall not em pl any person in any manner I � 0 so as to b co subject to the o 'er ) m nsa tion Laws. CLOTHES WASHER ADDRESS U Uatl 6f Applicant LU SWIMMING POOL RECEPTOR d NOTICE TO APPLICANT: 1f, afteZn<aking this Certificate of CITY TEL.NO `_ p cn Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. !� Z Compensation provisions of the Labor Code, you must forth- LICENSE NO.' obl �6" CLASS C. with comply with such provisions or this permit shall be WATER HEATER deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. ( P CESS D BY LICENSED CONTRACTORS DECLARATION / OUTLETS OVER � r/ � I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- - FINAL / V A L I DA /101\1 LJN ss and Professions Code, and my license is in full force and DATE effect. N^ ,9V C ° 6 FINAL License Number / Lic.Class��,, J BY Contractor Date D1 am exempt from the licensing requirements as I am a Plan Check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE ? �./ Lie.or Reg.Nn. Date Plan check applicant 223.5.6A HOME OWNER-BUILDER DECLARATION Name 5 1 hereby affirm that I am exempt from the Contractor's Address - License Law for the following reason (Section 7031.5, Busi- City Tel.No. 2 ° ° 1 2 5 0 ness and Professions Code): 1, as owner of the property, am exclusively contracting .° ° ° 1 2 5 0 v with licensed contractors to construct the project 1217-81 (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY - - I herebv 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 laws FOR ��^ lU'1��t 1 tlw. !!EE fl I certify that I have read this application and state that the ia` l �� C° above information Is eol agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the abov do dproperty for inspection purpo s. �a�/S/d/ Signat of Permittee Date WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers'Compensation Insurance, 76AG67A or o certified copy thereof (Sec. 3800, Lab. C. _ COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. CompanyYc f-r //s•',) ❑ Certified copy is hereby furnished. _ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDLDING RESS �/ �-• Codified copy is filed with the county building inspe - -` •. tion department. ,/�//,F NUMBER FIXTURE OR ITEM @ FEE Date G�—��'�� Appli<a rQ. -', - G ; 'V �s••�/ WATER CLOSET / mit LOCALITY NEAREST f ,J, CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB ,! - CROSS ST. ✓ COMPENSATION INSURANCE SHOWER -r OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS 1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in any manner SINK r CITY TEL. NO. so as to become subject to the Workers'Compensation Laws., DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ,,� ' NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY rr TEL NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE � LIC. • deemed revoked. WATER HEATER LICENSE NO. J ' CLASS �. LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm thatGAS SYSTEM OUTLETSl am licensed under provisions of Chapter 9 � � '/ •`/' —'/ O}.� (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER - _ O and Professions Code,and my license is in full force /and effect. 5 PER SYSTEM FINAL VALIDATION U License Number cZ �- Lic. Class p_, L-4r AM 7 V ��! ;') DATE 4 W FINAL u. Contractor &`G'-��" —�� BY } i am exempt under Sec, Ir, B.BP.C. for this reason , O Plan check fee 0.1Date: 2 PLUMBING PERMIT ISSUING FEE$ / ttJ Signature TOTAL FEE Plan check applicant a SINGLE FAMILY • HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section , j1O.:L v CJ 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY '•(�L,( 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 ) ° t`I)'f I", 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 oboe -mentioned proper for f� ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign lure of Permitteg• Date I