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Home My Public Portal About8838 LONGDEN AVE_Plumbing__ WORKERS COMPENSATION'DECLARATION I hereby,;affirm;that I have a certificate of,consent to,-self in- 760026 DPW 4✓87 App��'CC AT OpV FO111.;11 LMMy U�ILVCEJ, Il LAIR Vll� 11 surNP or certificate of Workers'Compehsation,lnsurance,of a" CE 817(REV. 8/86) certified•copy.thereof (Sec. 3800; Lab. C.) RK Policy Ne, Company, ' COUNTY OF LOS ANGELES, DEPT. OF.PUBLIC WO S Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) - - BUILDING Certified copy is filed with the county building inspection ADDRESS a 0 department.? NUMBER FIXTURE OR ITEM',, @ FEE LOCALITY, WATER CLOSET(TOILET) Date., ,Applicant NEAREST BATH TUB CERTIFICATE OF EXEMPTION FROM WORKERS" "• CROSs ST. INSURANCE OWNER This section need not be coin leted if the work involvedSHOWER the ermit is foF one hundred dollars $100 or lessby MAIC F. (, ) .) LAVATORY ADDRESS, I certify that in the performance of the work for which this per. SINK 041 yy,rr// G� mit is issued 'I shall not employ any person in any manner so r+�e7,!' AI as to become subject to-the Workers C pensation ws. . DISHWASHER - CITY TEL. NO. CONTRACTOR Date Applicant � � CLOTHES WASHER NOTICE TO APPLICANT: If,.after making this Certificate of Ex-. emption, yoush'ould become subject to the Workers'Compen- SWIMMING POOL RECEPTOR ADDRESS 0 O c CITY sation provisions of,the ^7� Labor Code; m 'YOU'r forthwith comp- :LAWN SPRINKLER SYSTEM 7 7 Iy with such provisions or this permit shall be,deemed revok- STATE /� LJC. ed WATER HEATER LICENSE NO. -�/ CLASS LICENSED CONTRACTORS DECLARATION . NO. PROCESSED By 1(hereby offirm"that I am licensed under,provisions of Chapter GAS SYSTEM OUTLETS ' 9;(commencing with Section 7000)of DivisioB n'3 of the usiness OUTLETS OVER Jr 'and Professions Code, and my license is in full force and ef- FINALS'_ 5 PER SYSTEM. q fect DATE - O 2 � P 1,� VALIDATION License-Number a 7o�.. .Lic. clpss ' U. /. .. FINAL �. Contractor ate o BY O Y I am exempt under Sec: LU CL B.BP.C.•for*this reason r Plan check fee Date: .PLUMBING'PERMIT ISSUING FEE$ D. Signature �Q , • - _ , TOTAL FEE SINGLE FAMILY "HOME OWNER-BUILDER;DECLARATION Plan check applicant' Y I hereby affirm that I am,exempt from the'Contractor's License Npme..' Law for'the following reason'(Section,7031.5, Business-and 77. Professions Code): Address Priya I,'as owner of the property,.will,'do the work and the City ,'Tel. No. EM Business ' structure is°not iritended;or offered for sale(S'ectiori 7044, _ i `"•'" ( ` {E t : Business and Professions,Code): 1 r{r Jn a 'CONSTRUCTION LENDING AGENCY. - �'"l• i, ( i - y Si D �`- I hereby affirm that there is a construction (ending agency for Nie performance of"the'•work for which this permit is issued L• ANG- (Sec: 3097; Civ. C.).; r Lender's Namel +l` ' D Ifiri 1L_ r Lender's Address' t #� ti 3 '`�='i I certify.that{I have'read this application and state,that the.. above information-is correct. I agree-to comply.witfi all County ordinancesand State laws regulating Plumbing, and hereby D' authori representatives of this County to enter upon the abov - entioned pro erty for insp coon/-purposes: C:�� SEE REVERSE FOR EXPLANATORY LANGUAGE Signa re of Permittee Date " WORKERS'COMPENSATION DECLARATION G;ll�l� {L��'G=J II DO� lIV FOR U"L�VUVII 0 �I1V�'; I!—LSI1�lIVv11�� 20-0026 DPW;4/87 I hereby, affirm that l have a certificate of consent to self in- 76A667A 'sure or.a certificate of Workers'Compensation Insurance,ora' CE 817(REV. 8L86)' certifued'.cop y,'thereof(Sec. 3800, Lab. C.) Policy No. Company OF PUBLIC OR COUNTY OF LOS ANGELES DEPT LK W KS_ , ` _ . . •„..: .: .: - .- ._ a:.,' .. Certified copy is hereby furnished. 'r BUILDING ¢ Y .Certified copy is filed,with the county-building inspection APPLICANT TO FILL TY ADDRESS O �� JUIN! FORA T N (PRINT:OR' PE) b 3� department.`- NUMBER FIXTURE OR ITEM Cal FEE C� Date A licant I LOCALITY pp WATER CLOSET,(TOILET). NEAREST �L5� CERTIFICATE OF EXEMRTION-FROM'WORKERS' BATH TUB L V�� CROSS ST. COMPENSATION.INSURANCESHOWER �� OWNERAct SSS. 2lla WYV = (This.section need not,be'coinpleted if the work involved by MAIL "" �a the permit is.for,one hundred dollars ($100)'or less.)' LAVATORY ADDRESSrJ"'�61�� ,.. ' I„certify that in the,performance of the work for which this per 3� Q mit is issued, I shall not employ any person in'ony-manner so SINK CITY b' TEL NO 1; subject to Compensation Laws. as to becomes DISHWASHER CONTRACTOR r`� to - DateJ 2, Applicant 111 I.. -CLOTHES WASHER v7 .'n//1(• F ADDRESS Y��6rn NOTICE TO APPLICANT If,;after'making his Certificate of Ex- SWIMMING POOL.RECEPTOR CA em ption,,you should become subject to the Workers'Compen- CITYI! L TEL. N U1 sation provisions-of the,Labor Code;you must forthwith crimp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit sF all be'deemed revok- 'STATE' LIC. . - ed: WATER HEATER LICENSE NO. 6�5 0 CLASS ” LICENSED CONTRACTORS DECLARATION": DISTRICT NO.. PROCESSED BY I hereby-affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS : 9(commenci'ng:vvith Section 7000)of Division''3 of the Business OUTLETS OVER D� fan�ed Professions Codi e,-and my license is n'full force and-ef- 5 PER SYSTEM FINAL- VALIDATIONDATE License Number I U'S D Z Lic.'Clasa V FINAL r Contra'ctor�2 rA�.l /� Date -� ?`, BY. (� /��i v O ❑ I am,exempt under'Sec. UJ. B.&P.0 for this reason ' t.• -Plan check"fee,- Dater PLUMBING PERMIT ISSUING FEE.$ ` Signature TOTAL FEE SINGLE FAMILY Plan heck applicant. HOME-OWN ER-BU ILDEc R DECLARATION .` I.hereby affirm that lam exempt from the Contractor's.License Name Lawfor.the following reason (Section 7031.5,Business and , Professions Code): Address'. )t'1"('g • .e r , t rr _ a I, as owner.of the property, -will do the work and the City Tel No. , " structure isnot intended or offered for'sole(Section 7044,. Business and Professions Code) i w, CONSTRUCTION LENDING AGENCY:.• _ _ • _ .. I Hereby affirm that there is a construction lendin a enc forilrz•`; `=r I Y 9 9 Y the performance of the work for which this permit is issued - (Sec. 3097,'Civ. G.•).. CH"•, E a Lender's-Nome i J iIJ Lender's Address1-6 1E I certify that I have read this application and state that the 593 above.inforination is correctA agree to comply with all County° D ordinances and State laws regulating Plumbing,-and hereby authorize representatives-of this County to enter'upon the above mentioned property for inspection purposes. <3 SEE REVERSE'FOR EXPLANATORY LANGUAGE Sign ture..of, ermittee Date