Loading...
HomeMy Public PortalAbout9218 LIVE OAK AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9/89 APPLICATION FOR PLUMBING PERMIT 76A667A I hereby affirm,that I have a certificate of consent to self insure, ora certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company ❑ Certified copy is hereby furnished. BUILDING j ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS � Vk_ Certified copy is filed with the county building inspection / J department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY Date Applicant WATER CLOSET 00 NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 0 O CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE 00 PARCEL OQ 6 permit is for one hundred dollars($100)or less.) OWNER Ai �✓ n� A I certify that in the performance of the work for which this permit 3 LAVATORY Qd is issued, I shall not employ any person in any manner so as to MAIL " become subject to the Workers' Compensation Laws. � SINK L9 00 ADDRESS J DISWASHER 0� CITY TEL.NO. Date 3 i `Applicant CLOTHES WASHER l�0 CONTRACTOR NOTICE TO APPLICANT: If, after maki"f'g is Certificate of Exemption, you should become Subject to the rkers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forth ith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM ©Q LICENSED CONTRACTORS DECLARATION CITY TEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 1Z WATER HEATER 30 QQ 0 (commencing with Section 7000 of Division 3 of the Business and STATE LIC. ( 9 ) ME / Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS / 00 LICENSE NO. CLASS OUTLETS OVER DISTRICT NO. PR ESSED BY cc 5 PER SYSTEM 8 License Number Lia r Class -- tFINALATE �/W VALI ATION LU ATE p Q Contractor Date _ co ❑ INAL I am exempt under Sec. Y B.&P.C.for this reason Date: Plan check fee ,� 0 v Signature PLUMBING PERMIT ISSUING FEE$ ❑ TOTAL FEE _r Plan check applicant `t SINGLE FAMILY I_y'T HOME OWNER-BUILDER DECLARATION Name ir I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address Code): E—.E City Tel. No. I TG �.' 1, as owner of the property,will do the work and the structure TOTAL 230 65 is not intended or offered for sale (Section 7044, Business - and Professions Code). , fy{� { Lc CONSTRUCTION LENDING AGENCY CHANGE ,Si31 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.) 0013I-1303 i 1 4.r' 7/93 Lender's Name �Sl`t�ry'I S'2�. NIS ^°�°_ 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 above-mentioned propertys ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature 6Y Permittee bate ION WORKER'S I have a certificate of consent to 76A666DPW9/89 APPLICATION FOR PLUMBING PERMIT 76A667A 1 hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company, Certified copy is hereby furnished. BUILDING FI APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS V� O Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY 1`� Date Applicant WATER CLOSET NEAREST - CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. COMPENSATION INSURANCE BATH TUBASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK (1 PAGE V O PARCEL OD permit is for one hundred dollars($100)or less.) OWNER I certify that in the performance of the work for which this permit LAVATORY is issued, I shall not employ any person in any manner so as toSINK MAIL become subject to the Workers' Compensatio Laws. ADDRESS DISWASHER CITY TEL.NO. Date E ? Applicant CLOTHES WASHER NOTICE TOA PLICANT: If, after making thisCertificate of CONTRACTOR Exemption,you should become subject to the Work, 'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000) of Division 3 of the Business and STATE LIC. 0 Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS 0 OUTLETS OVER DISTRICT NO. PROCESSED BY O 5 PE YSTEM �p U C License Number Lic.Class FINAL /� VALIDATION 0 DATE` LIJ V 1{0—? a Contractor Date fn ❑ FINAL Z I am exempt under Sec. BY BAP.C.for this reason Date: Plan check fee , , Signature PLUMBING PERMIT ISSUING FEE$ Q ❑ TOTAL FEE r Plan check applicant - SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address Code): City Tel. No. i i T E1- I, as owner of the property,will do the work and the structure 1 is not intended or offered for sale (Section 7044, Business -I e i % ,fl R. and Professions Code). , CONSTRUCTION LENDING AGENCY y� 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 _ 4.-H i.»p i 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 above-mentioned :Ii= 4 poses. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Pe ml tee Date