HomeMy Public PortalAbout4959 MCCLINTOCK AVE_Plumbing__ .>duoRKl`Rs'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
' 1 hereby, affirm that I%av`e a certificate of consent to self in- 76A666 DPW a/87
sure'AP cerofi ate of WoFkers'Compensation Insurance,or a- 76A667A
P CE.817(REV.8/86)
'certifietd'*�eopy th reof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy Noo Company
❑ .Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the county building Inspection I I ADDRESS
department. NUMBER FIXTURE.OR ITEM @ FEE
LOCALITY
WATER CLOSET(TOILET)
Date Applicant 1,!!0b10 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' D2, BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER O OWNER
(This section need not be completed If the work involved by
the permit is for one hundred dollars 100 or less. LAVATORY, MAIL t
P (S � ) �Q ADDRESS
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY ` TEL. NO.
as to beco ;sAect to the Workers'Compen; on LC WS. DISHWASHER
! CONTRACTOR
Date Applicant. CLOTHES WAS O
NOTICE TO AP LICANT: If, after making this Certificate of Ex- ADDRESS 57
emption,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR
CITY �n NO.)II 774
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER D LICENSE NO. 57 CLASS C .3
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER a
and
d,Professions Code, andmylicense is in full force and ef- 5 PER SYSTEM .FINAL 17, VALIDATION �
�/�- I tp 3 . Lic.'Class 6—� DATE `^3}
License Number 0
V
FINAL
Contractor TIA A -!Al Date BY O
I am exempt under Sec. UJ
�� IV
UJ
B.BP.C. for this reason loo.check fee •
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE p p
- SINGLE FAMILY Plan checkapplicant
HOME OWNER-BUILDER DECLARATION r�
I hereby affirm that I am exempt from the Contractor's License Name v
Law for the following reason (Section 7031.5, Business and
Professions Code): Address ;�
il307
I, as owner of the property, will do the work and the City Tel. No. 1 �.
structure is not intended or offered for sale(Section 7044, ITEMS
Business and Professions Code).
TOTAL _13 B 00
CONSTRUCTION LENDING AGENCY , CHECK a .CIJ
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CHANGE .110,
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address 6555 1 Ail 7,.5,7,
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
authorize representatives of this County to enter upon the
above-mentionpd—rope for insp ction purpo es.
��eg/� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee rDate!
p. f WORKERS;CQMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
uhereby affirm thus I Have a certificate of consent to self 20-0026 DPW 6/87
nsure}or d certificate of workers'Compensation Insurance, 76A667A
4r a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
P01i41SIc+t Company
Cer.tified copy is hereby furnished:
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING f' t/� (
Certified copy is filed with the county building inspec- ADDRESS. Y'1
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY MS C
Date Applicant WATER CLOSET NEAREST //�� �//��
((��
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB
CROSS ST.t„�lyC_11 Cl
COMPENSATION INSURANCE OWNERANN 9.8h
Z2-0
(This section need not be completed If the work involved by SHOWER
the permit is for one hundred dollars($100)or less.) LAVATORY O MAIL
ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall.not employ any person in any manner SINK CITY
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date applicant CLOTHES WASHER ADDRESS
NOTICE. TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL.NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked: WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 0�
(commencing with-Section 7000)of Division 3.of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL1:3 VALIDATION
License Number Lic. Class (� U ! ' Q DATE ,q C
C
pS4 6A)s ZionQ FINAL a
Contractor Date BY C
I am.exempt under Sec.
F.
B.BP.C. for this reason Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE �®
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
'1 hereby affirm That I am exempt from the Contractor's License Address HYD
Law for the following reason (Section 7031.5, Business and �_i =;
rot sions Code): City - Tel. No. a Ir` .�E�,,„5:_
i 1, as owner of the property, will do the work and the Z;yfTjL
structure is not intended or offered for sale (Section
7044, Business and Professions Code). ® j i ITA1 50 -50
CONSTRUCTION LENDING AGENCY �;Ecl og:
I hereby affirm that there is a construction lending agency for
• :_:K
the performance of the work for which this permit is issued. CHANGE .1,0
(Sec. 3097, Civ. C.).
Lender's Name
Lf s:lraf
Lender's Address
I certify that I have read this application and state that the -6
above information is correct. I agree to comply with all County
a an s nd State laws regulating Plumbing, and hereby
uth r' r pre"sentatives of this County to enter upon the
abo - is Toned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
6�
lure of
emit a Date