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HomeMy Public PortalAbout9443 LAS TUNAS DR_Plumbing__ WORKERS'COMPENSATION DECLARATION; �r/k ! ; 20-0026 DPN%'4%87 ar b afhrm'.,that,I have a.certificate aficonsent to self in- APPLI. TION AOR"P`LUM�ING PERMIT. to Y ., 76A667A. si e or a certificate of-Workers'Compensation,Insurance`ora"' CE:817(REV. 8)86) - certified copy-thereof (Sec.`3800„Lab,C ) .. y I 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 '+•„ l' Certified copy is filed with the count'y'building inspection G� r ADDRESS (' department:< r @” LOCALITY NUMBER ',' FIXTURE OR:ITEM FEE r Date Applicant y T) NEAREST WATER CLOSET(TOILE --CERTIFICATE OF'EXEMPTION FROM'WORKERS " BATH TUB CROSS ST COMPENSATION INSURANCE SHOWER , OWNER AA ad0-, (This section need`not be completed if the work involved by MAIL the permit is for'one Wundred dollars (Sf00)or less;) LAVATORY ^ " ADD Lceiiify..thatln'the'pe�formance of.the work,for which this per- . . -. SINK - • CITYRES `TEL NO .. �a s mit is'.issued, l'shall',nof employpny person-in an -,manner,so.:, as to become subject to"the Workers Com ensation Laws. DISHWASHER . ° {� CONTRACTOR O vc_ 1° Date/ ' `aApplicant CLOTHES WASHER _62 `� 'ADDRESS NOTICE TO APPLICANT:'If; after ma g t iSrCertific6le of E3<-*' SWIMMING RECEPTOR, :emption,'you should become subject1o'the Workers'Compen CITY TEL. NO. cation provisions of the-Labor Code you,musNorthwith comp- LAWN SPRINKLER'SYSTEM ly.with such provisions or,this permit shall be deemed-revok- ed. WATER HEATER'. STATE d�qi LIC LICENSE NO. V .CLASS. 316. LICENSED,CONTRACTORS DECLARATION, DI TRICT NO ROCESSED BY ' GAS SYSTEM 60, ,I hereby.offirm that I am-license under proJisions of:Chapter w A - OUTLETS 9(commencing with,Section 7000)of,Division 3 of the*'Business, OUTLETS OVER i S PER SYSTEM and Professions Code> and my license is.in full force.and of FINAL - 6 VALIDATION a feet qgg e. -� ��i�.: DATE ! �' 0 . License'Number �i4.t Lic: Class14" ( U BD g N i g 4 Contractor t� '' Date .Ir,am exempt,under•Sec a z . P.C%C for-this reason Plan check fee ' q z Date: a 1 4 G 0 - •PL'UMBING PERMIT ISSUING FEE$ ' .# G o'"o a o 5 '+ Signature TOTAL FEE .© 87,50. . . . SINGLE FAMILY. Plan check a licant �o 0 0:' HOMEOWNER-BUILDER DECLARATION.V PP C�7,-5 0,' ' -I,hereb offirm-that I am exem t from the Contractor's License Y' P. Name Law.for the following reason (Section 7031.5; Business and "Qi ' '2.3. 8 8 Professions Code): Address -1`, as owner;of the property,'will do• the work and the City Tel. No ;'structure isnot mtended•or'offered for-sale(Sect6d7044, _ Business and Professions Code`) ' CONSTRUCTION LENDING AGENCY ; I:hereby affirm.'that;kere.is a construction.lending,agency for the perforrriance':of the work for which'thIS permit is issued ,(Sec 3097 Civ. C:) r Lender's Name Lender's Address` h'at.I hgJe read this application'.dnd_state,that;the abo efinformation is correct. I bgrbe to comply with all County Y L. ordinances and S64 laws regulating Plumbing„and hereby authorize representatives,of.this County to; enter upon the a - 1 above=m 'tiohed proIperty,ffor"inspection purposes._ SEE REVERSE FOR EXPLANATORY LANGUAGE Sig,at re.of Permittee Date ' ,N T , „" .. '~ /L RKER 'C.3MPENSATION DECLARATION . I 11 _ '• :b< '.:, .t `m 20 0026 DP.W;4%87 ,-�►PPLICAThON'-:F.OR PLUM INC P RAi1IT I;hereyY:,affirm that hTSaGe'a certificate of'consent;to,seIf in .,76A667A I sur`e,:or"a~certificate of Wb kers�Compensafion;lnsurance,or a;:,•k ;CE 817 R V / is } ( E 8.86) '"•�tif, -'-, y ther�ief (Sec..3800, Lab C ) u t ' "` u . «' /I 3' COONTY;,OF LOS ANGELES DEPT :OF. P..UBLIC.WORKS Policy'Not! yG!�>fv�i� =Company.1 IV�I '[Cr 'IL Q Certified copy,is hereb"y furnished y ' iy w'. :.:• - ;,.� - .a ,,-+° _r;, .:;_f. ' OR,APPLICANT TO FILL;,1N (PRINT OR+TYPE) .BUILDING, ; �7 Ceftified copy'is filed with th`e'Coun"ty building i'n'spectiop ".; F - ADDRESS ,` 1141 NUMBER "'FIXTURE'-OR ITEM " @ FEE depart ent h. ` :F ,F LOCALITY , A Q a v WATER CLOSET(TOILET) Date !' 4 Applicant .NEAREST ) a 11. ` �' ' ".r .BATH TUB:`, f « CROSS STS CERTIFICATE OF EXEMPTIONtFROM WORKERS W 01< COMPENSATION.INSURANCE �" SHOWER " OWNER ' fj , t � w (This section need not be completed if the;�ivork involved by. MAIe ' 'the`" -1. . is•f'Fj Fie'hundr`ed Iolidesr$ 60)'o�)esii LAVATORY-` P .a ,. ( ' ) ,� `k ADDRESS . a 1. I'cert,fy'th_of m the performance of-t which,this p'er- , .a -mlhis,s'sued I'shall not'em% p oy-,any person-ih anymanner-so-." "=-i.+.',- p' SINK _ 1 •`F - •TEL, NO ' CITY • as to become subject' he_:Workers Compensation Laws c F,- `': b. r' r✓ i,:_ 1 CONTRACTOR:. DISHWASHER f C. v Date Apphcani `- ` Ak a=CLOTHES WASHER r-: r . ADDRESS ,� y /, NOTICE,TO'APPLIC'ANT If".after making this Certificate'of Ez SWIMMINGPOOCRECEPTOR'- r empt,on.:you should become sublectto the Workers`Gompen :, CIT_Y'.., .. TEL NO ry ..- Aq' - •sahon provisions'o£the Labor Code,;you.mu"stsforihwith core p:. 1. ,f _' _W -,SPRINKLER SYSTEM. ''s - tit. Q. /�d Y= P PV. t,' I with such rovisions or this erm-it Shall'be deemed revcIO,, ; LIC ,ed , :'1-.". , . -- -WATER HEATER - C ASS ' .l NO LICENSED CONTRACTORS'.'DECL'ARATION: >•.; "" NSE DISTRICT NO PROC SS :BY STAT '� ,.f:.. .,. ,... .. .. -'' '` .. GAS,SYSTEM »!- OUTLETS LICE P �( _ _1 ',I.hereby:affirm'that l}am;licensed under pro'vis,ons of'Chapter, 9(commencing ivith,Section 7000)of,D,vision`':3.of the Business ,=':OUTLETS OVER ;j`, :; . ^5'.,PER:SYSTEM and Profess,ons"Code,- d my license,,s in`full.force`arid ef; FINAL /� v t V fect ;' _ E' O q�x. AL . [[LL tuber �T. L,c Class # - DAT V IDA ION I .1 License Nu FIN �, Contractor 0-1 i Date _✓ BY. O e H I am exempVunder Sec . Q. L '� - '. % 1. J % y. 7 ,d B BP.0 for this reason' Plgh check fee y ,. . ®. Ir. Z ate r PLUMBING PERMIT.ISSUING FEE $ Signature " zt� 3,7,A v, e _ - 4. - - '� TOTAL;LFEE - o:,o o e o r.tINGLE FAMILY v : # Jr ` '' ,:` Plor check'a licant I -'4 HOMEOWNER=BUILDER,DECLARATION pp ;:: 5 0= c\ V 4 .. .h 'i, O C'`�0 I;Fiereby,,aff,rm,thaf I dm exempt'from.the Contractor,-s License t Name. 1 6.5 0 U Law for the•foll'owin`'.redson'- S'ection_7031`5,. Business,and''` ' r i , ., 4 9 Y Professions Code) ' ^Ad'dress 5 s t 1. t1. " I13 8 I as`owner,;.of thI.e,property,,w,ll do the vy- k,bnd the,,,) City' Tely Ncx ' tiY r st�'ucture is nat`intended or offe[ed Eorsale(S60icin 7044; s Business ard,. rofessions Code) % 4, ,i,. T ..aC.r Y - _ - CONSTRUCTION A!5)I G.AGENCY , , . c �' t T hereby:affirm tF at there is a consituction,lend,ng agency for T `•r the per"formance of the work for.which this'.permit is issued: % I �, } I 1. (Sec 3097, Gv C.,) ' Lender s Name s Lender s Address e y; e redd:'fhis a licatwn;d d,state+that tL I he-• " cerh£ that I,hav PP c, 7 v. above information is coreect:I agree•to comply withal)County;;= x n ord,nan.ces and State laws.regulating.Plumbing,!and°hereby.' r® tee -,, .. a - • :.:k: , P. .y ,,,t•enter .upon.the_ y. autt onze",yre resentat,ves,of this Count ?a osesi" ' above ment,onedrproperty,for'i ispe,ct,on pu.p : I ', "e a z r �• .1 r �'. y SEE REVERSE FOR EXPLANATORY LANGUAGE,' - ,. ` Y 5, t ✓ ' 'at" e;`of Permittee ate ".- ., , .G.., , I,