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HomeMy Public PortalAbout5626 MCCULLOCH AVE_Plumbing__ ION ti e WORKER'S I have a certificate of consent to 20-0026 DPW APPLICATION FOR PLUMBING PERMIT .•I hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance,or a certified copy 1h*rdbf(Sec.3800 Lab.C.) Policy No„-I202 //�� �'T))� �Ld6I y-9 Company. \4MO� COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. �_ F1Certified copy is hereby furnished. BUILDING L/�u//00/ a v� ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS b�f0 1. h �I Certified copy is filed with the county building Inspection department.Q n / j ,f CONUMBER FIXTURE OR ITEM @ FEE ti Date 9rs �ti l./1.►�'e CLOCALITY e t` \ Q��Applicant A. WATER CLOSET NEAREST I CROSS ST. L` � Qi OQ! CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work Involved by the SHOWER MAP BOOK , PAGE 3 PARCEL Z permit is for one hundred dollars($100)or less.) OWNER I certify that in the performance of the work for which this permit LAVATORY IAIL !'` /+ l is issued, I shall not employ any person in any manner so as to SINK ADDRESS S 16 1A�C Cw l OC►1 AV become subject to the Workers'Compensation Laws. DISWASHERCITY amp 1.4 TEL.NO.yy Date Applicant CLOTHES WASHER , t CONTRACTOR tv NOTICE TO APPLICANT: If, after making this Certificate of ® pt S T Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code,you must forthwith comply with such ADDRESSN14 r provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION y CITY 2 r' TEL.NO47, _ }I hereby affirm that I am licensed under provisions of Chapter 9 f WATER HEATER (� O (commencing with Section 7000)of Division 3 of the Business and STATE LIC. Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. © S 3 O CLASS OUTLETS OVER DISTRICT NO. p PROCESSED BY qq �O License Number�Jf� 5 PER SYSTEM 0 _ 3 Q Lic.Class /Q pp ,,,/ FINAL DATE ! _ G VALIDATION a Contractor80k I+,6k* C0�J , Date �� // co ❑ I am exempt under Sec. FINAL Z DO BY B.&P.C.for this reason Plan check fee , PLUMBING PERMIT ISSUING FEE$ +� p Q Signature�► v - ❑ TOTAL FEE SINGLE FAMILY - Plan check applicant 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): City Tel.No. ❑ I,as owner of the property,will do the work and the structure o too not intended or offered for sale(Section 7044, Business and Professions Code). , I _ ^r"+V ��n [I , 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.) ^y tt 114/213/91/ Lender's Name ��/ A.� Llr=r I AM 2:57 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 .�; WORKER'S COMPENSATION DECLARATION 2o-0028DPW9189 APPLICATION FOR PLUMBING PERMIT �f'heseby'8ffilm that Nave a certificate of consent`to self insole, 70 67A or a certificatq of Worker's Compensation Insurance,ora certified copy toareef(Sec.3800 Lab.C.) Policy No 0024 ' ompany f6 AAt A 21 COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING fN / e ❑ Certified copy is filed with•the county building inspection ADDRESS J(9 (� C OC A Ake, department. 1, Yn( L} ) /� NUMBER FIXTURE OR ITEM ® FEE 9 C Date 7-27 J 0 Applicant r 0kb u✓rt,A'T�. `® WATER CLOSET LOCALITY I �. NEAREST j /V A_ CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. C. (Jq 16 COMPENSATION INSURANCE ASSESSOR ¢ (This section need not be completed If the work Involved by the SHOWER MAP BOOK o 7 PAGE 13 IFRCEL permit Is for one.huhdced.dollars($100)or less.) OWNER ' 1 certify that In the performance of the work for which this permit LAVATORY ` MAIL ► / QW1;' Is Issued, I shall not employ any person In any manner so as to SINK ADDRESS _50". r C ✓� become subject to the Workers'Compensation Laws. �/,� DISWASHER56 CITY• ) • . TEL.NO. _ ► Date Applicant CLOTHES WASHER O NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTO r► e. Co 1i s Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS provisions of•the Labor Code,you must forthwith comply with such e 4 provisions or this permit shall be deemed revoked. LAWN SPRINKLERSYSTEM } LICENSED CONTRACTORS DECLARATION CITY �� r TEL.W. I hereby affirm that I am licensed Under provisions of Chapter 9 WATER HEATER (commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS o LICENSE NO. ©S,3(� LIC. S Professions Code,and my license is in full force and effect. V OUTLETS OVER I DISTWCT NO.ve Q Q 5 PER SYSTEM • + Q License Number / ®���® .. Lic.Class - V FINAL �� V ID W Contractor• h W t`i'e- "amu'Date 7� ,f DATE � ❑ FINAL Z I I am exempt under Sec. FBY B.&P.C.for this reason :!2 Me _ Plan check feenatu PLUMBING'PERMIT ISSUING FEE$ 131ou , ❑ TOTAL FEE SINGLE FAMILY Plan check appiicant HOME OWNER-BUILDER DECLARATIONName J ACCT I hereby affirm that I am.exempt from the•Contractor's License Law CC 73.00for the following reason(Section 7031.5, Business and Professions Address 33 Code): , ❑ City Tel.No. 1 ITEMS I,as owner of the property,will do the work and the structure is not Intended or offered for sale(Section 7044, Business TOTAL 7:r --■ 0 and Professions Code). , CHECK73.00 , CONSTRUCTION LENDING AGENCYHAf� �'- I hereby affirm that there is a construction lending agency for the CRAWL performance of the work for which this permit is Issued (Sec.3097, Lender's Name /dAlE 7/30M01 2106 1 Ali 7411 , Lender's Address. I certify,that I have read this application and state that the above Poll.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 WORKERS'COMPENSATION DECLARATION "20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT r�t� 1,hereby, 4ffISin thpt I have a certificate of co0sent to self in- '76A667A '1 I sire,-._Ndertificate of Workers'Compensation Insurance,or a. CE 817(REV.8/86) lul c€r{iQ cgpy thereof(Sec. 3800, Lab. C.) Policy No!" Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING��/ MCC v o Certified copy is filed with the county building inspection ADDRESS (p f`rl 1. department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY P r Date Applicant WATER CLOSET(TOILET) NEAREST CROSS ST. BATH TUB CERTIFICATE OF EXEMPTION FROM WORKERS' �/ COMPENSATION INSURANCE SHOWER. OWNER (This section need not be completed if the work Involved by MAIL ,I the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK '- N'-'-Lr'—JrJ mit is issued, I shall not.employ any person in any manner so CITY TEL. 4 7 as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date. Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY TEL. NO. sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION TRI N¢„ OCES D Y I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS SC,( 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER 9, fed,Professions Code, and my license is in full force and ef- 5 PER�SYSTEM FINALQf #ALIDATION d DATE `/ O License Number 'Lic. Class U FINA cc Contractor Date BY O F1 I am exempt under Sec. W B.BP:C, for this reason ► Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ 150 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 �t eg h� Professions Code): Address AC CTA •as owner of the property, will do the work and the City Tel. No. 3307• 1�■ structure is not intended or offered for sale(Section 7044, 1 IT Business and Professions Code). i• Poo TOTAL �.,�®!�(� EM CONSTRUCTION LENDING AGENCY, CHC 1 hereby affirm that there is a construction lending agency for W7G{iK 16.50the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). ■00 Lender's Name 9/ 8' Lender's Address 55.86.7 a I certify that I have read this application and state that the A11o.�}7 above information is correct. I agree to comply with all County popordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above tinned property fo�Ins tion Purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature o Permittee Dae > r