The URL can be used to link to this page

Home My Public Portal About5527 MCCULLOCH AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION ;�5;AP'"19/ ' APPLICATION FOR PLUMBING PERMIT 1 hereby'af(Irm test I have a certificate of consent to self insure, ora cec'Ificate of Wor�CBr's'Compensation Insurance, or a certified" copy thergof(Sec.3800 Lab.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company Poli Certified copy is hereby furnished. BUILDING •1• ❑ la �FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS- G V/ Certified copy is filed with the county buildinginspection department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant s WATER CLOSET 30112 "' NEAREST DA ,k ST. KI CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB OR �. COMPENSATION INSURANCE ASSESSOR (This section need not be completed If the work Involved by the 2, SHOWER MAP BOOK PAGE PARCEI,�� permit Is for one hundred dollars($100)or less.) LAVATORY OWNER W&jAwiZig A. I certify that in the performance of the work for which this permit Z is Issued, I shall not employ any person in any manner so as to SINK ADDRESS 2 G t(. become su ject t the Workers'Compensa to aws.j DISWASHER CITY 4V C-1 pi—er TEL.NO�(y 57�' 5b Date 5 Applicant CLOTHES WASHER NOTIG TO APPLICANT: If, after a of CONTRACTOR Exemption,you should become subject tb pensation SWIMMING POOL RECEPTOR provisions of the Labor Code, ye us forth 'th such ADDRESS ASU provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. a I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000)of Division 3 of the Business and CENSE NO. CLASSTE Professions O Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS V ! OUTLETS OVER DISTRICT NO. PROCESSED BY X13 5 PER SYSTEM O License Number 66.523-7- Lie.Class FINAL DATE VALIDATIONIL Contractor %44 d=94 Date HC-CT at Z El am exempt under Sec. BY j ,j 3313 119.io— B.&P.C.for this reason - 1 T V D Plan check fee 8� 010. 10 Signature PLUMBING PERMIT ISSUING FEE$ i "i � '�-19 j El TOTAL FEE �`1 i.H i i9` �SINE FAMILY ?Ian check applicant ` to-314f CHANGE °CIO HOME OWNER-BUILDER DECLARATION Name `- I hereby affirm that I am exempt from the Contractor's License Law 0001-D-00111 /mac/��r for the following reason(Section 7031.5, Business and Professions Address Code): City Tel.No. u° r ❑ 1,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 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 Co ty o enter upon;theabov4e-m;n;floned property, specti�n p os SEE REVERSE FOR EXPLANATORY LANGUAGE Si tt�e Dat n .WORKER'S COMP NSATION DECLARATION 20-0028DPW 9,a9 APPLICATION FOR PLUMBING PERMIT I hereby affirm t#�at'f'have a certificate of consent to self insure, +• 7tiA867A or a ceftificaib of Worker's Compensation Insurance, or a•certifled copy thereof(Sec.3800 Lab.C.) , Policy No. Company COUNTY OF'LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF,PUBLIC WORKS DIV. ❑ Certified copy is hereby❑ furnished. B DING .� FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS � Certified copy is filed with the county building Inspection department. NUMBER FIXTURE OR ITEM G FEE LOCALITY Date Applicant WATER CLOSET NEAREST ICAAO E2 01W CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.mileffi BpT11 TUB - COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK �� 3 PAGE�,rPARCEt9*9-4"' permit is for one hundred dollars($100)or less.) LAVATORY • OWNER I certify that in the performance of the work for which this permit r MAIL Is Issued, I shall not'employ any person in any manner so as to SINK' ADDRESS become subject to the-Workers'Compensation Laws. j DISWASHER CITY TEL. Date Applicant CLOTHES WASHER CONTRACTOR -NOTICE TO APPLICANT: If, after making this Certificate of f��y Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ` ADDRESS provisions of the Labor Code,-you must forthwith comply with such provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. > I hereby affirm that I am licensed und..er provisions of Chapter 9 WATER HEATER 0; (commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS CENSE NO: LIC. V Professions Code,and my license is In full force and effect. 5 PER�YSOTEM DISTRICT NO. PROCESSED BY ER License Number Lie.Class /,/,� J Af v� FINAL 1J/.-7 V�LI� a r DATE DATION Iti Contractor Date - - - L ❑ I am exempt under Sec. BINAL ` ■g 8.8P.C.for this reason. .30} 57.30 Date: Plan check fee dooll.. I PLUMBING PERMIT ISSUING FEE$ 0 ITEMS i� � Signature �� ElTOTAL:FEE -713 � TOTAL 57 - 30 CHEC� �� -�. Plan check applicant 1 ■3 5 SINGLE FAMILY CHANGE ■0I3 HOME OWNER-BUILDER DECLARATION Name• I hereby affirm that I am exempt from the Contractor's License Law' for the following reason(Section 7031.5, Business and Professions Address Code): Lltl-0113�.iI/ / ': 'E] 1,as owner of the property,.will do the work and the structure City Tel.No. 7499. i PCS 5=58 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 readAhis 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 PrOgerty far i ecti urpos s. SEE REVERSE FOR EXPLANATORY LANGUAGE •. ,Signature of Permittee• Date