HomeMy Public PortalAbout5753 LOMA AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION2026 APPLICATION FOR PLUMBING PERMIT
I�ereby,$ffirm that I have a certificate of consent to self in- 76A-06067APW 4/87
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
certified copy thereof (Sec.,3800, Lab. C. fl_
d �-- COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. j. �Jo4ompony
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING �^—
�X Certified copy is filed with the county building inspection ADDRESS s J L
LSI department. NUMBER FIXTURE OR ITEM @ FEE a 11)4
LOCALITY
t/, WATER CLOSET(TOILET)
Date �Applicant � NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB / CROSS ST.
COMPENSATION INSURANCE SHOWER f(J OWNER L
(This section need not be completed if the work involved by MAII
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY e!�/f �� �+1 TEL. NO.
as to become subject to the Workers' Compensation Laws. DISHWASHER
CONTRACTOR wO
Date, Applicant CLOTHES WASHER C
NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS Q 9 Pe 2v_5
SWIMMING POOL RECEPTOR _
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM /®/��
ly with such provisions or this permit shall be deemed revok- STATE 7 > LIC.
ed. WATER HEATER LICENSE NO. / / CLASS 13
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER _5�
d Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VAL112114TION
fe
DATE
License Number Lic. Class 13 O
34- 7 I
U
c �/ FINA g
Contractor-3W � Date 0 ` BY O
I am exempt/under Sec.
:99722A
B.BP.C. for this reason to
Plan check fee ► # o 0 0 ° ° 5
�f Date: PLUMBING PERMIT ISSUING FEE$ ( o o 3 4,5 0
Signature L r TOTAL FEE 1 S^ o o o 3 G,5 0
SINGLE FAMILY / v
HOME OWNER-BUILDER DECLARATION Plan check applicant
04,3.1 --88
1 hereby affirm that I am exempt from the Contractor's License Name _
Law for the following reason (Section 7031.5, Business and
Professions Code): Address .
❑ I, as owner of the property, will do the work and the City Tel. No.
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.). n/
Lender's Name /"n/49 /
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-I ent' ne�roperty for inspection purposes.
.cam s AySEE REVERSE FOR EXPLANATORY'LANGUAGE
Signature of Permittee Date
76A667-CE917 .12/59 - '
APPL
COUNTY OF 'LOS. ANGELES
DEPARTMENT OF 'COUNTY ENGINEER
BUILDING,AND SAFET4Y RlVISION:. BUILDING71
AMBIE
JOHN A LCouNTYn NGINEER ADDRESS
,'WILL°IAM.A�""JENSEN4iSupT.,oF"^BUI�Io�Nre ^Q
ILIFOR xAPPLICANTTO�FILL�IN
�-
NEAREST �= a F CROSS ST
' NUMBERFIXTUREOR�ITEM
OWNER
WATER.CLOSET MAIL': J'�
BATH°TUB ` ADDRESS. ,
CITY TEL NOS / _ 3q� 3
SHOWER ..'.,
a' • LAVATORY
CONTRACTOR � �
SINS ADDRESS T
• .. CITY'; '. TEL. NO. r
DISHWASHER
LAUNDRY TUB RCO
CONTRACTOR'S J r STATE ❑
EGISTRATION NO. - /_ Lj- �. UNTY. ❑'
I CLOTHES;WASHER DISTRICT NO. GRO P 'I Z E PROCE�s BY "
WATER HEATER
GAS SYSTEM
INDUSTRIAL:
WASTE,'APPROVAL
INSPECTION=RECORD' S.
U'
? y :yO
@ $1.00 PER ITEM M
r OR FIXTURE' _$ AFOROVALS DATE INSPECTOR'S SIGNATURE; f •'"
. .: 'PERMIT' $ ,. . .2 00 ,UNDER SLAB WORK
" TOTAL FEE
ROUGH PLUMBING
- _. ,. .. .:- GAS PIPING .. .. pp. d. ��;p .
'C HEREBY-'ACKNOWLEDGE .THAT I HAVE READ THIS AP.PLICATION'; :GAS VENT f f.. a :�fjft
'AND STATE THAT THE ABOVE, IS CORRECT AND AGREE T0-COMPLY.? �{
"r WITH ALL COUNTY ORDINANCES AND STATE-LAWS REGULATING-PLUMBING. '- HOTWATERHEATER lt'.{,
I -HEREBY,.CERTIFY CERTIFY-THAT I 'AM PROPERLY' REGISTERED AND/OR:'. PLUMBING'-FIXTURES.
'LICENSED,ASS.,REQUIRED•BY.LOS,ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA''_0R.,THAT',I AM `THE,LE6AL OWNER OF-THE ABOVE:
,DESCRIBED'RES[DENTI'AL' PROPERTY.=.: NOTIFIED.'..
UTILITY CO.
i 'SIGNATURE:
I `, .OF PERMITTE FINAL
y®F v . VAI:IDATION ROBERT AIWOOD F I
cs. SUPERVISING MECHANICAL ENG R
.:GS .FEB,� a G In,�
1
5