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Home My Public Portal About5746 LOMA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 76a667A I hereby affirm that I have .a certificate of consent to self 61E en(z-ad) APPLICATION FOR PLUMBING, PERMIT insure, or a certificate of Workers'Compensation Insurance,or j�a certified copy thereof(Sec..3800 Lab.C.) s COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NoJu SL� Company �� /`�/J�//C ��i'''G Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ADDRESS Y I�/ (}j • Certified copy is filed with the county building inspection• NUMBER FIXTURE OR ITEM ® FEE LOCALITY da�fnent. �� ^/�l�Ma/7 ' ( WATER CLOSET. NEAREST G �( Date / Applicant (� /,/ / 11 BATH TUB CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' — COMPENSATION INSURANCE SHOWER OWNER / LAVATORY MAIL (This section need not be completed if•the work involved I ADDRESS by,the permit is for one hundred dollars ($100) or less.) SINK tL > CITY TEL. NO. O 1 certify that in the performance of the work for which this DISHWASHERV c - CONTRACTOR permit is issued, I shall not employ any person in any manner J 0,,177 so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER ,�7 Date Applicant ADDRESS / F tr>� �rOP— SWIMMING POOL RECEPTOR /) / U NOTICE TO APPLICANT: If, after making this Certificate of CITY GOT r� TEL. NOZ" LU Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM _ P 0. STATE �/� LIC. N Compensation provisions of the Labor Code, you must forth- LICENSE NO. S j J CLASS Z. with comply with such provisions or this permit shall be WATER HEATER deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. P S D BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section.7000) of Division 3 of the Busi- FINAL �ry� DATE VALIDATION ness and Professions Code, and my license is in full force and ` G�Ol' effect. License Number � 5� Lic.Class BY.AL / ' C % (�,°" .�—Date Contractor -i I am exempt from the licensing requirements as I am a Plan check fee licensed architect or a registered professional engineer PLUMBING-PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOT AL FEE Lic.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name hereby affirm that I am exempt from the Contractor's Address License Law for the following reason-(Section,7031.5, Busi- City Tel.No. - ness and Professions Code): �2.4 0.,1 A DI; as owner of the property, am exclusively contracting with licensed contractors to construct the , project # o o 0 o of (Section 7044, Business and Professions Code). 2-oto-1 u 0 0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency to 0 0 1 6 0 0 for the performance of the work for which this permit is U issued (Sec. 3097,Civ.C.). 0 ,09-8T 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 SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentio d property for inspection purposes. Signature of Permittee Date WORKER'S COMPENSATION DECLARATION DPW 969 76A667 APPLICATION 1=0R PLUMBING PERMIT 76A667A I hereby affirm that t have a certificate of consent'to self insure, or a certHicate 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. P❑olicy.No. Company _ Certified copy is hereby furnished. BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Certified copy is filed with the county building inspection �� ee �T -department. NUMBER FIXTURE OR ITEM On FEE LOCALITY �. Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS',^ BATH TUB CROSS ST.. COMPENSATION INSURANCE ASSESSOR y (This section need not be completed if the work involved by the SHOWER MAP BOOK ��' PAGE PARCEL permit is for one hundred dollars($100)or less.) OWNER,JUc S& V.�J��>t,v�C I certify that in the performance of the work for which this permit LAVATORY ��C. t // is issued, I shall not employ any person in any manner so as to SINK MAIL become subject.to the Workers'Compensation Laws. ADDRESS I ' DISWASHER i CITY /rl ,b, ,�� TEL.NO.`?/3 y� Date Applicant / CLOTHES WASHER CONTRACTOR NOTICE-TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS nAA'n provisions or this permit shall be deemed revoked. AWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. I hereby affirm that l am licensed under provisions of Chapter 9 WATER HEATER / a (commencing with Section 7000) of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO.r CLASS STATE LIC. O Professions Code,and my license is in full force and effect. ' OUTLETS OVER DISTRICT NO. PROCESSED BY 5 PER SYSTEM. �O Y License Number Lic.Class FINAL ,-',� ( (ice VAW DATE LIDATION W a Contractor Date.- /' W ❑ FINAL Z I am exempt under Sec. BY BAP.C.for this reason !/ Plan check fee• Date: - -PLUMBING PERMIT ISSUING FEE$ _ Signature ❑ TOTAL FEE p - Plan check applicanty --; SINGLE FAMILY _.-_.... �• . s._... HOME OWNER-BUILDER DECLARATION Name 1 Oj j I hereby affirm that I am exempt from the Contractor's License Law '°I€1 for the following reason (Section 7031.5, Business and Professions Address Code): I _ I T E ME, ❑ City Tel.No. :'i:' 6,c m 40 1,as TOTAL �AL owner of the property,will.do the work and the structure is not intended or offered for sale (Section 7044, Business r. h at—i and Professions Code). CHECK CONSTRUCTION LENDING AGENCY :{11V " ' �311 ' 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.) is^s �1 Lender's Name, AIic!- 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 "property for inspection purpo-sZle. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date ION WCPVKER'have a certificate of consent ON 76A666DPW9189 APPLICATION FOR PLUMBING PERMIT 76A667A I hereby afflrm�that I have a certificate of consent to'self insure; - or a certificate of.,Worker's Compensation Insurance, or a certified copy thareof(Sec. 3800 Lab.C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.. Policy No. Company Q . Certified copy is hereby furnished. J y - FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Ey Ji 00 ��/ e` lw ) . Certified copy is filed with the county building inspection' ADDRESS�l ��/ /r"' fi ( C� F1 department. NUMBER FIXTURE OR ITEM - @ FEE ,LOCALITY Date Applicant WATER CLOSET NEAREST OF CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST: COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or Tess.) ¢ LAVATORY OWNER O S'�, �l L I certify that in the performance of the work for which.this permit V is issued, I shall not employ any person in any manner so as to SINK MAIL ADDRESS6 l P511/P, 4�j 7 In, / / V t/p�,. (IO Me Pprllc become subject to the Workers' Compensation Laws. L DISWASHER CITY / ,Jt TEL.NO. Odd Date Applicant CLOTHES WASHER vr+ CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. �- I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER n. (commencing with Section 7000) of Division 3 of the Business and STATE LIC.LICENSE NO. CLASS O Professions Code, and my license is in full force and effect. GAS SYSTEM OUTLETS a OUTLETS OVER DISTRICT NO. PROCESSED BY 5 PER SYSTEM License Number / Lic.Class FINAL DATE ,��j VALIDATION a ! � }p- Contractor Date (n ❑ FINAL Z I am exempt under Sec. BY BAP.C.for this reason ' Date: Plan check fee PLUMBING PERMIT ISSUING FEE$ Signature ❑ TOTAL FEE n Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name — •;-. -, I hereby"affirm that I am exempt from the Contractor's License Law e _for the following reason (Section 7031.5, Business and Professions Address Code): y; + City Tel.No. r _ ❑ 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 I certify that'[ 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'bf this County to enter upon the above-mentioned pro pe ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ftnat6re/of Perflilitibe face ur 17glige •D1Z , PL-d, Jost- I-f LP/-F