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Home My Public Portal About9624-9626 LONGDEN AVE_Plumbing__ FP_ ' f WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMPING PERMIT �:"'hefebyt ffirm thpt I ba •era(certificate .of consent to self 76g667q welsure,e.o certificat. o}Workers'Compensation Insurance, CE 817.(REV..10781) , oda certified copy thereof(Sec..3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS �.0.� Certified copy is filed with the county building inspec- -i JAJiN_ tion department. NUMBER FIXTURE OR ITEM ® FEE LOCALITY DaAppliSan' WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM RKERS' BATH TUB CROSS ST. • COMPENSATION INSURANCE SHOWER OWNER t (This section need not be completed if the work involved by MAIL y 9i fhe permit is for one hundred dollars($100)or less.) -LAVATORY ADDRESS 2-2-''10 , W.. 1v ek I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY .N so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date'r~' . S 9 O —26 Applicant +• CLOTHES WASHER �. w NOTICE TO APPLICANT: If, after makin this 'Certificate ADDRESS Exemption-, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY TE N (� LAWN-SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LI deemed revoked. WATER HEATER LICENSE NO. d CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. ' PROCESSED BY I hereby off irm-that I am licensed under.provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000).of Division 3 of the Business OUTLETS OVER. 511 and Professions Code,and my license is in full force and effect. 5 PER'SYSTEMFINAL w3 4: DATE VALID, ION License Number•��✓� ®7 Lic. Class C C FIN L Contractor '' Date .- B Ell am exempt under Sec. B.&P.C.'for this reason Plan Check fee EL Date: U, PLUMBING PERMIT ISSUING FEE$ Zr Signature 41 All" TOTAL.FEE g, Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address ;P4 7 9.6 A Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. # 0 ?.0.0 0 5 ❑, I, as owner of the property, will do the work and the structure is not intended or offered for.sale (Section , ( o,0 2 a.5 0 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 0' 0,,- 2a5 O C5 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is,issued 0 6 1 0•7 $6 (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 regulating Plumbing, and hereby outhoriz epresentatives of this County to enter upon the abov. Zionpro erty for inspection purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE g ture of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT L 'IiRerely affirm that I �ave a certificate of consent to self 76A667A %Q rip, or a certificate of Workers'-Compensation Insurance, CE 817(REV. 10/81) u orb certitled.copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) Certified.copy is filed with the county building inspec- ADDRESS oO tion department. NUMBER FIXTURE OR ITEM (gi FEE n LocAurr , Date Appligant 6 WATER CLOSET U I✓ NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB #0 CROSS ST. COMPENSATION INSURANCESHOWER /�� OWNER r, (This section need not be.eomplefed if the work Involved by L9 MAIL the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK 4,0 CITY TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER �{ CONTRACTOR a � DateApplicant CLOTHES WASHER a/ ADDRESS G° C NOTRC TO APPLICANT: If, after makin this Certificate Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL N 7�� Compensation provisions of the Labor Code, you must forth- Su` LAWN SPRINKLER SYSTEM _AW I with -comply with such provisions or this permit shall be E STAT ✓ -� CLASS I m deeed revoked. WATER HEATER LICENSE NO. 77 LICENSED CONTRACTORS DECLARATION DISTRICT NO. ESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000)of Division 3 of the'Business OUTLETS OVER 71 and Professions Co and my license is in full force and effect. 5 PER SYSTEM V FINAL VA ATION S 0-7a DATE License Numb Lic. Class 10 C FIN C Contractor4Date BY 0 ❑ I am exempt Inder Sec. F B.BP.C. for this reason- G Plan check fee -2441.7A u Date. PLUMBING PERMIT ISSUING.FEE$ ® 'e Signature # 0 0 0 0.0 5 TOTAL FEE �"' Plan check applicant i I 33 4 5 0 SINGLE FAMILY3 34.5 0 HOME OWNER-BUILDER DECLARATION Name o 0 76 I hereby affirm that I am exempt from the Contractor's License 1 Address Law.for the following reason (Section 7031.5, Business and 0410-86 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 1 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 a boye-7nentioneddd��property for inspection purposes. •/ SEE REVERSE FOR EXPLANATORY LANGUAGE Z �a ° Si natu4oermittee I Date WORKERS'CO*PENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I1c-rel r offiro that I have a certificate of consent to self 76A667q i'ri LLf6.., or..0,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 , y ❑ Certified copy is filed with the county building inspec ADDRESS 26 f)on department. NUMBER FIXTURE OR ITEM FEE gg /� LOCALITY Date Applicant WATER CLOSET /� V NEAREST CERTIFICATE Of EXEMPTION FROM WORKERS' Z BATH TUB CROSS ST. COMPENSATION INSURANCE ZO SHOWER ! oOWNER,&j (This section need not be completed if the work Involved by /� MAIL the permit is for one hundred dollars($100)or less.) LAVATORY 2 Qp , ADDRESS l I certify that in the performance of the work for which this ^ permit is issued,I shall not employ any person in any manner SINK fJ v CITY TEL..NO. so as to become subject to the Workers'CQmpensaiirgn Laws. DISHWASHER �a 7// o� CONTRACTOR Date Applicc. �. CLOTHES WASHER Z ADDRES • NOTICY TOAPPLICANT: 'If, after making this__C_e_r_tRcatd of SWIMMING POOL RECEPTOR l Exemption, you should become subject to the Workers' l T� CITY TEL. NtS Compensation provisions of the Labor Code, you must forth- Y� Z`t LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC: deemed revoked. WATER HEATER12- /)D LICENSE NO: CLASS LICENSED CONTRACTORS DECLARATION 1 V DISTRICT NO. OCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM /IgL OUTLETS Z 0 9 A (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER ✓ VV and Professions Code,and my license is in full force and effect. 5 PER SYSTEM D DATE FINAL V IDATION License Number3M.0-7Lic. Class C FIN L Contract44. s Date BY it C ❑ I am exempt under Sec. ;P-4 4 1,6 A t, LL B.BP.C. for this reason Plan check fee ® #.0 0 0 0 0 5 U Date: PLUMBING PERMIT ISSUING FEE$ S Z Signature ;( o,1 4 8 5 0 r TOTAL FEE0 Ul Plan check applicant • 0014&5plp SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name OIL 1 Q a 8 6 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 loop7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY t 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 regulating Plumbing, and hereby authorize representatives of this County to enter upon the above'-menti ed pr party for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE r �Date ig ature of P ittee