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Home My Public Portal About9614 LAS TUNAS DR_Plumbing__ 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. 10/81) or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. - FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING //�J / � ❑ Certified copy is filed with the county building inspec- ADDRESS CO 7 (�j� / 9Y tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS,ST._ COMPENSATION INSURANCE OWNER SHOWER (This section need not be completed if the work involved by MAIL / // /✓J , ,�1�^ the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY �� TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR /�J�-y `,- Date Applicant CLOTHES WASHER ADDRESS � �- /w NOTICE TO APPLICANT: If, after making this Certificate of 15 Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR //1� ']]� Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY �_ TEL. NO. with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER (� and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL 3�i DATE psi C/ VALIDATIO n}._ License Number Lic. Class 0 �/� %16FI Contractor // 6' Date .y,' 1� N 0 1' . I am exempt under Sec. � B.BP.C. for this reason /i Plan check fee pW,• &ZgIv, ate: 7 (n PLUMBING PERMIT ISSUING FEE$ Z. Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I 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). 2 5 4 a 4 A CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for # • • • • • 5 the performance of the work for which this permit is issued • • 2 2 5 0 (Sec. 3097, Civ. C.). • 2250 Lender's Name Lender's Address 0 9 2 3=8 6 1 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 au thorize eprentatives of this County to enter upon the oproper or inspection purposes. �j' �f SEE REVERSE FOR EXPLANATORY LANGUAGE / —�—R. Signature of Permittee Date ION DECLARATI WORKER'S I have a certificate of consent to 76A666DPW9/89 APPLICATION FOR PLUMBING PERMIT 76A667A I hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified i copy thereof(Sec.3800 Lab.C.) COUNTY OF LOS ANGELES d DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No. Company ❑ Certified copy,is hereby furnished. �— r-1 FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ,Ll 4A Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY ✓�-, Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS BATH TUB 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($100)or less.) OWNER I certify that in the performance of the work for which t1is permit MAIL LAVATORY is issued, I shall not employ any perso in a manner so as to SINK ADDRESS become subject to the Workers'Compe s tion aws. (1� .1 DISWASHER CITY TEL.NO. Dat r applicant CLOTHES WASHER NOTICE TO APPLICANT: If, er ti t is Certificate of CONTRACTOR Exemption,you should become s bje to the Workers'Compensation SWIMMING POOL RECEPTOR [� provisions of the Labor Code, ou ust forthwith comply with such ADDRESS 111;913 3 Lf` f �js provisions or this permit shall b emed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY /�. C> TEL.NO �� I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER Cv/ �/ i Q, (commencing with Section 7000) of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO 6 CLASS r ° Professions Code,and my license is in full force and effect. (� OUTLETS OVER DISTRICT NO. rev PROCESSED BY 5 PER SYSTEM v'� License Number Lic.Class �`� qo !/ llii U T FINAL y �DATE ,� VALIDATION a � Contractor Date FINAL //�� ' I am exempt under Sec. By / c Z F1 BAP.C.for this reason A(;[ a Date: Plan check fee rl_'1 .7 PLUMBING PERMIT ISSUING FEE$ 3307 Signature 1 1 T ENO 50.cc TOTAL FEE �,. � 1-1Plan50 m Plan check applicant 55 SINGLE FAMILY _ CHECKclocr HOME OWNER-BUILDER DECLARATION Name 1 hereby affirm that I am exempt from the Contractor's License Law .00.00for the following reason (Section 7031.5, Business and Professions Address CHANCE 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 i i0ljl-1_00111 =7'177/73 and Professions Code). , 53235 1 M 9:21 e1 CONSTRUCTION LENDING AGENCY rw'i 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 law regulating Plumbing, and hereby authorize representativ of this Co to enter upon the above-mentioned pr ert for' s coon r uses. SEE REVERSE FOR EXPLANATORY LANGUAGE nature of erm ttee Date