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Home My Public Portal About10213 LOWER AZUSA RD_Plumbing__ +� WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9/89 lee:Vby.affirm that I have a certificate of consent to self insure, 76A667A APPLICATION FOR PLUMBING PERMIT or a certificatp of Worker's Gompensat nsurance, or a certified copy here f ec 3800 Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No� Compo ❑ Z01 z2 Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Certif' d copy' filed with the ounty bui g inspection de rtmQnt. NUMBER FIXTURE OR ITEM @ FEE (� CALITY Date Applica WATER CLOSET D, NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS 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($100)or less.) LAVATORY d OWN R I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as toSINK MAILO ADDRE become subject to the Workers'Compensation Laws. �y DISWASHER CITY TEL. Date Applicant CLOTHES WASHER CONTRA O NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRE Q provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CIT TE I hereby affirm that I am licensed under provisions of Chapter 9STATE LIC. WATER HEATER (commencing with Section 7000) of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. , CLASS Professions Code,and my license is in full force and effect. (� OUTLETS OVER DISTRICT NO. PROCESSED BY ,/may 5 PER SYSTEM Licens umber v Lic.Class 0 If Is FINAL /J,� DATE _ Z VALIDATION Contra or Dates C0 r-1 IFINALI am exempt under Sec. BY B.&P.C.for this reason Date: Plan check fee , � Signature PLUMBING PERMIT ISSUING FEE$ ❑ TOTAL FEE D Plan check applicant , SINGLE FAMILY _ HOME OWNER-BUILDER DECLARATION Name --• -- I hereby affirm that I am exempt from the Contractor's License Law -iLi_ z s•-- ii for the following reason (Section 7031.5, Business and Professions Address -- 14'-"'- Code): -._• ❑ City Tel. No. I, as owner of the property,will do the work and the structure m is not intended or offered for sale (Section 7044, Business _ - and Professions Code). ► f� ! '' ' ' V. 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.) _If i 3'? -fi li - _. , _ _ ; __ 't._=i ii�n. 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 rresentatives of this County to enter upon the above-mentioned p ope in spec i urposes. — SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECL,gPW 4/90 RATION20-0026 APPLICATION FOR PLUMBING PERMIT I hereby, affirm th_a�t I have a certificate of consent to self in- 76A667A sl;; ,or I?.certificaTe of Workers'Compensation Insurance,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. BUILDING - FOR APPLICANT TO FILL IN(PRINT OR TYPE) 17 a 3 / L F-] Certifiedcopy is filed with the county building inspection ADDRESS Q �f1 �f S department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY C i Dote Applicant WATER CLOSET(TOILET) AlNEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. 'COMPENSATION INSURANCE SHOWER OWNER 0-7(This section need not be completed if the work involved by J MAIL c� the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS / �.Z /-fc)/Lt I certify that in the performance of the work for which.this per- SINK CITY �� TEL. NO. ��✓�J mit is issued, I shall not employ any person in any manner so1�,4 as to become subject to the Workers'Compensation Laws. DISHWASHER — iL- 4� y. j CONTRACTO �^ ' C�� Date ' / Applicant CLOTHES WASHER ADDRESSJfVf AvgDyz NOTICE TO APPLICANT: If, after ma ing this Certificate of Ex- SWIMMING POOL RECEPTOR empiion,you should become subject to the Workers'Compen. CITYgW- �j AA TEL. NO. / sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE oLIC. ed. WATER HEATER LICENSE NO.&7 CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that 1 am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER (f _ 5 PER SYSTEM `; �(IDATION and Professions Code, and my license is in full force and ef- � FINAL fect. ��f / HOSE BIB DATE �� '(1�� t °° >_ License Number 'G" Lic. Class v _ 1 7 ___.z= 0 �/ ,:j fc ' O / FINAL 0 i.,.._ Contr Date BY 4= := cc I am exempt under Sec. I1„1 sr f - = 65 V B.&P.C. for this reason oil. i. 1'-'- Plan check fee = =Y CA Date: PLUMBING PERMIT ISSUING FEE$ %.. Signature ^ . - TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant - I hereby affirm that I am exempt from the Contractor's License Name ;” Law for the following reason (Section 7031.5, Business and Professions Code): Address ❑ 1, as owner of the property, will do the*work and the City Tel. No. 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 regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. . SEE REVERSE FOR EXPLANATORY LANGUAGE S' nature of Permittee Date