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Home My Public Portal About9588 LOWER AZUSA RD_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) T �r St certified copy thereof /h�e�re fa(Ses 3800 L b C ) COUNTY OF LOS ANGELES / � � BUILDING AND SAFETY Policy No I a� Company ❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the cou ty building in ec ADDRESS9588 Lower Azusa Road tion d par ment NUMBER FIXTURE OR ITEM ® FEE LOCALITY Date Appljgant WATER CLOSET NEAREST ERT ICATE OF EXEMPTION FROM WO& S BATHTUB CROSS ST Temple CitBlvd COMPENSATION INSURANCE OWNS (This section need not be completed if the work Involved by SHOWER MAIL the permit is for one hundred dollars($100)or less) LAVATORY ADDRESS 10127 Towneway Drive I certify that in the performance of the work for which this permit is Issued I shall not employ any person in any manner SINK 0� CINEl- Monte, Ca TEL NO — so as to become subject to the Workers Compensation Laws DISHWASHER CONTRACTOR Arthur Ka lwara Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR 2205 Trny Avenue Exemption you should become subject to the WorkersTE Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM c1TYS0 E1 Monte ` NO686-0800 with comply with such provisions or this permit shall be STATE LIC deemed revoked WATER HEATER LICENSE NO CLASS 0— LICENSED CONTRACTORS DECLARATION DIST CT NO PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS S` O r/ (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER d d and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL _ VALIDATION V DATE License Numbera/ . —f� Lic Class d-2(0__ _/ � OR FINAL .>/ O Contract ate ❑ I am exempt under Sec . y B&P C for this reason Plan check fee Z Z Date PLUMBING PERMIT ISSUING FEE$ () s C) Signature TOTAL FEE SO Plan check applicant SINGLE FAMILY HOME OWNER BUILDER DECLARATION Name Arthur Kajiwara I hereby affirm that I am exempt from the Contractor s License Address "fi ? 2 fi Law for the following reason (Section 7031 5 Business and Professions Code) C'N So E1 Monte Tel No686-0800 1 4 0 0 0 0 0 ❑ I as owner of the property will do the work and the ? 0 0 ` 2 structure is not intended or offered for sale (Section 7044 Business and Professions Code) 10, 0 o v 2 G 90-1 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 100.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 ned�propertyforection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o ermit ate WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 1 h4reby affirm that I have a certificate of consent to self in 76 66�A DPW 4/87 sure or a ce(tifcate of Workers Compensation Insurance or a CE 817(REV 8/86) cent¢ied copy,the�of Sec 800 Lab C �� a� / COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS Policy No Company n 12--'Certified copy is hereby furnished FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 4 �j A Q Certified copy is filed with the county aujldin inspection ADDRESS SBS 1-0 W�/1 zks+T dZ/, w,r_ NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date ,rWATER CLOSET(TOILET) NEAREST CERTIF TE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST COMPENSATION INSURANCE SHOWER OWNER N �� 1 OhI/yL ( F( C- (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars($100)or less) LAVATORY ADDRESS tfS I certify that in the performance of the work for which this per SINK r` /�� mit is issued I shall not employ any person in any manner so Q CITY � R` Q N e_ TEL NO�f-,C 2-080 as to become subject to the Workers Compensation Laws DISHWASHER l CONTRACTOR C ,n,.rJ ` Date Applicant CLOTHES WASHER Q �O NOTICE TO APPLICANT If after making this Certificate of Ex ADDRESS Z v-& emption you should become subject to the Workers Compen SWIMMING POOL RECEPTORAr sation provisions of the Labor Code you must forthwith comp CITY 17yTEL P Y P LAWN SPRINKLER SYSTEM U� ly with such provisions or this permit shall be deemed revok STATE LIC ed ! WATER HEATER D O LICENSE NO LICENSED CONTRACTORS DECLARATION r DISTRICT N PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 0 A 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER (J and Professions Code and m license is in full force and of 5 PER SYSTEM aS fecta Y DATE __,LIDATIONCL License Number '� o Lc Class F O ^� i 0 !� 3 oZ FINAL t�y`i y T a V It Contractor �r 3� Date 1/ I� BY 1 am exempt under Sec V 1 n ITEMS W B&P C for this reason Plan check fee ► N PTAL 21 ®13 z Date PLUMBING PERMIT ISSUING FEE$ CHECK �a1 Lr Signature TOTAL FEE GE SINGLE FAMILYatl HOME OWNER BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor s License Name w Low for the following reason (Section 7031 5 Business and (,) W-[il01 1(.}/24r,- ,1 Professions Code) Address W , f 4� 1 Ali _a.�! I 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 ,097 Civ C --4 M �n Lender s Name .dl Ct7 I Lender s Address --i I certify that I have read this application and state that the 1� . rn 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 y above menti d property for inspect purposes L 0 SEE REVERSE FOR EXPLANATORY•LAaUUAGE 4?, Signature of Permittee Date G