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HomeMy Public PortalAbout5614 LOMA AVE_Plumbing__ 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, 76A667A . or a certified copy thereof (Sec. 3800, Lab. 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 C / �I Certified copy is filed with the county building inspec- ADDRESS `l tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY C 1 WATER CLOSET Date Appligoril NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION.INSURANCE SHOWER OWNER -V (This section need not be completed if the work Involved by MAIL the permit is for one hundred dollars ($100)or lose.) LAVATORY ADDRESS �(✓ f��'� I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY­—/:�, �� TEL. NOO so as to bec e suect to the Wor s'Co pens ws, CSS e_ nY7/�I DISHWASHER CONTRACTOR D Applican)',� � "' CLOTHES WASHER NOT E TO APPLICANT: If, after making this Certificate of ADDRESS SWIMMING POOL RECEPTOR Exemption, you should'become subject to the Workers' Compensation provisions of the Labor Code, you must forth- CITY TEL. NO. LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. ' WATER HEATER �� LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm-that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS Q (i (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL 37 VALI_ DATION .1 DATE License Number lic. Class FINAL Contractor Date BY W t..w_ El s..� I am exempt under Sec. I€1 a, a .LLI CLI B.&P.C. for this reason r-tc--jr ' *',e.$ Plan check fee � � t _ . U) Date: -Z PLUMBING PERMIT ISSUING FEE$ 7� 4 ti••ii mr -Signature -..._ TOTAL FEE C Plan check a licant SINGLE FAMILY � - 1, HOME OWNER-BUILDER DECLARATION Name �L x15!!57, .# AN t hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section.7031.5, Business and Address_ J0�/f, Professions Code): �r City ell', C/ � Tel. No. OJ— �L I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 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 1 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 v -e tio 'property for inspection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date 76AG67 DBS 17 7-51 " - - APPLICATION FOR PERMIT DEPARTMENT OF BUILDING AND SAFETY COUNTY OF LO$,ANGELES WILLIAM J. FOX, CHIEF ENMINEER' FOR APPLICANT-TO FILL' IN ISTR :C GRD P O P PLUMBER ypLIII 17V 411 C1�17f'i OI 11�tlII?IRIt` /1e'ii RECEI ED BY READY FOR DATE. ISSUED rlr...t�. Tc....c— ,T,,,,r�... C9. FIRST INSPECTION ADDRESS 0nn. 17ACT \/Al I CV Di n AA CITYC AAE= D TEL.No. ATI. 2 _71.. _ADDRESS COUNTY ",�j LOCALITY LICE SE I NO, h EXPIRES e� — @NEAREST - PERMIT FEES CROSS ST. NUMBER TYPE OF FIXTURE OR ITEM FEE OWNER MAIL WATER CLOSET(TOILET) O.SO- S 'ADDRESS BATH TUB 0.50 CITY 'TEL. No. SHOWER 0.50 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS f LAVATORY (WASH BASIN) !�-_0.50 APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES ._ KI'T'CHEN SINK - 0.50 AND STATE LAWS REGULATING PLUMBING. 1 CERTIFY THAT 1 POSSESS THE ABOVE VALID LOS L >,•`.;d,' ' AUNDRY TUB OR TRAY 0.50 ANGELES COUNTY LICENSE, OR I AM THE LEGAL OWNER TLETB -x .0.50 OF THE RESIDENTIAL PROPERTY DESCRIBED ABOVE. GAS SYSTEM_�! OLF SIGNATURE c WATER HEATER 0.50 "'MITTE c.w SLOP SINK 0:0.50 INSPECTION RECORD .FLOOR SINK 0.60 a-,-) FLOOR FLOOR DRAIN 76 13.513 7 �//�/✓'E'.,�.y -� as-.�.C� �ryS�� . o . DISHWASHER ® 0.50 DRINKINGFOUNTAIN 0 O.BO d5;=Ir 7 'd57S7' C==111 4,:P' ©� ~ URINAL 0.50 /V O 47"ldfg4gvl HOUSE SEWER 0.50 - � ia.t _Z MISCELLANEOUS" 3 O APP`ROUALS DATE INSPECTOR'S NAME ROUGH PLUMBING GAS PIPING ` GAB VENT CESSPOOL 1:00 CESSPOOL SEPTIC TANK: SEPTIC TANK DRAIN ( ) PIT O 7.00 SEWER / - PERMIT I 1.00 GAS TEST UTILITY CO.NOTIFIED TOTAL FEE `& / FINAL V /