The URL can be used to link to this page

Home My Public Portal About9565 LAS TUNAS DR_Plumbing__ r • 1 , WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING. PERMIT' ,affirm that I have a certificate of consent to self 76A667A., Ira certificate.of Workers' Compensation Insurance;.; 'CE 817(REV.8/86) died copy ther.'eof (Sec, 3800;Lab. C.) COUNTY. OF,.LOSANGELES` DEPT. OF PUBLIC Company .WORKS rtified copy is hereby furnished FOR.APPLICANT TO FILL IN(PRINT OR TYPE) : BUILDING' J ( (� rtified copy is,filed with the county building inspec ADDRESS J.� LAYS �✓w .' n dortmen P e t. NUMBER" FIXTURE OR ITEM @ FEE LOCALITY L - WATER CLOSET' " NEAREST. Applicant ' _ CROSS ST. _-ERTIFICATE OF EXEMPTION FROM'WORKERS BATH TUB r 'COMPENSATION'INSURANCE OWNER ;SHOWER tion'need not be completed if-the work'involved`byl MAIL , - Iit is for one hundred dollars($100)or less.) LAVATORY.. C • '. ADDRESS �. that in the Fe'rformance of,the work for which thisl issued, (shall.not employ any person in any manner .. -SINK CITY. TEL NO '•- ' become t e subjIcto the Workers'Compensation Laws ` P ?-DISHWASHER CONTRACTORS Applicant :CLOTHES WASHER ADDRESS f0 APPLICANT If, after making+'this Certificate of( SWIMMING POOL RECEPTOR n you should become subject to the Workers - CITY TEL. N ration provisions of the Labor Code, you-must forth- _ - - V�,.'IW' �4� LAWN SPRINKLER SYSTEM nply with such'provisions or this 'permit shall be STATE nn -7 (� LIC revoked. 6 ; '. I WATER HEATER NSE NO.2 LY,0 :(-0'' . SS LICE CLASS ,LICENSED CONTRACTORS DECLARATION E , DISTRICT NO.. OCE ED BY affirm thaYl am licensed under.provisions of Chopter.9 GAS SYSTEM OUTLETS icing with Section 7000)'of,Division 3'of'the Business' ' OUTLETS OVER fssionS Code,�ancl my license Is in full foice and effect. 5'PER'SYSTEM FINAL 2 40 7 C� . . TE�✓Lid'G/ '` V DATION+ DA dumber Lic. Class tr" LQfny ?si►,r •l L d Fl Date m exempt under Sec. W.C. for.this reason A Plan check fee' 7 2.2.5 Date: # • e • . e 5 ' PLUMBING PERMIT ISSUING FEE$'• Q' Iria tur TOTAL FEE •°e 1 0' 1 6.50 HOME OWNER-BUILDER DECLARATION Nameheck applicant O SINGLE FAMILY - - dffirm that I am exempt from the Contractor's License } the following-reason (Section 7031.5, Business and Address, _ �`` • ns Code): City TeL No'. )s owner'of'the property„will do the work and the kture is:not infended. or offered for sale (Section 14,.Business and.Professions Code). CONSTRUCTION LENDING AGENCY affirm that there is a construction lending agency for ` rmance of the work forwhich this,permit is issued r- 7, Civ. C.). Name :h Address application and state that,,the that I have read this a , formation is correct. I agree to comply with all County es,and State laws r ulaIing Plumbing; and Hereby , t repre tatives.olthis County,to-enter upon the. d roperty or inspection purposes. SEE•REVERSE,FOR EXPLANATORY LANGUAGE..' i of Permittee. Date - .. WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby,affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 8/86) 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 / LAS Certified copy is filed with the county building inspec- ADDRESS l� J!� Voo tion department. NUMBER FIXTURE OR ITEM FEE LOCALITY r Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. � t COMPENSATION INSURANCE SHOWER OWNER LI CLOG S �s�Te GDC (This section need not be completed if the work involved by MAIL C the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS J Aflvl I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR`?-�A4 q.I MG-MO4?LIJ A,A 1iA,4 Date Applicant CLOTHES WASHER ADDRESS�3 WIRD• S-r. NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR 7 Exemption, you should become subject to the Workers' CITY TEL. NU.1 Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM A4, 2,41 with comply with such provisions or this permit shall be 7 STATE ryn L. - LIC. deemed revoked. WATER HEATER LICENSE NO. �+--L O / - CLASS C-.1- LICENSED rLICENSED CONTRACTORS DECLARATION DISTRICTNO. OCE D BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �j (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ` o and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL 2 Lt 0 7 C�' ,� 5Tr,,+� (p DATE�� V DATION O License Number Lic. Class 0 Ott t,ln►G"b .kI'll Iz Contractor LV A4 A t M C � Date 4 ❑ V I am exempt under Sec. W -27225Aa B.BP.C. for this reason ► to Plan check fee Z D te: PLUMBING PERMIT ISSUING FEE$ Q # �'� 5 Signature TOTAL FEE ` D e .� 1650 Plan check applicant - - 16505 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name 06, 10-87 1 hereby affirm that I am exempt from the Contractor's license Address Law for.the following reason (Section 7031.5, Business and Professions Code): City Tel. No. ❑ 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 I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws r ulating Plumbing, and hereby author'ze repre tatives o this County to enter upon the ab o - d roperty r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE G "t 047 ignature of Permittee ► Date ,f