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Home My Public Portal About5941 MUSCATEL AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION �ft —PLICATION FOR PLUMBING PERMIT F`hereby affirm shakl he�c a certificate of consent to self in- 76A667A �� ®� IY,® PERMIT sure,ora certific,�!aof Workdrs'Compensation Insurance,or a' certified copy thereof(Sec.•3800, Lab. C.) Policy'No.A1825!"V gmpony �i°�'�.�8�- /NI�2/iJW/7COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Certified copy is hereby furnished. Certified co is filed with the count building FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING copy y g ins tion NUMBER FIXTURE OR ITEM @ FEE ADDRESS SCj V �T�.L. department. LOCALITY , Date �i��r�5 Applicant WATER CLOSET(TOILET) a NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This (This section need not be completed if the work involvod by MAIL the permit is for one hundred dollars($100)or loss.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK ° mit is issued, I shall not employ any person in any manner so 2 CITY TEL.NO. as to become subject to the Workers'Compensation Laws. DISHWASHER rr CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS CITY �L�Jvq�O�� TEL. NO !y^�� ly with such provisions or this permit shall be deemed revok- / STATE LIC. ed. / WATER HEATER LICENSE NO. (p ,5 CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ry 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER j/ and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION fect. HOSE BIB DATE License Number 45330 Lic. Class C�`� J IL IL _ y O FINAL V Contractor.5;A-!- /�� Date �� IJ +� r BY I 3393 333.20 Q I am exempt under Sec. ® 1 ITERS B.&P.C. for this reason Plan check fee ® TOTAL 33-3 o 20 12 Date: PLUMBING PERMIT ISSUING FEE$ C�{ECK 333,20 3 Signature TOTAL FEE � C}�,Ait;[yE .00 SINGLE FAMILY 3� HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name QII00-0001 11/13/95 Law for the following reason (Section 7031.5, Business and o Professions Code): Address 3271 1 AN 9042 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. 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 r gulating Plumbing, and hereby authorize represe fives pff this County to enter upon the above-me i p oper for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per ttee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby, affirm that I have a certificate of consent to self in- 76A66 A 4/90 sure,or a certificate of Wrjrkers'Compensation Insurance,or a certified copy 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 /_ F-1Certified copy is filed with the county building inspection ADDRESS S &,42e_ department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET(TOILET) Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed If the work Involved by MAIL the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK CITY TEL. NO. mit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Co pensation Laws. DISHWASHER CONTRACTOR Date. SZ /19(,—Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after ma ing this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY TEL.NOqla ye sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS / LJ ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. _2_ -2– CLASS L Z LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS I 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER ! and Professions Code, and m license is in full force and ef- 5 PER SYSTEM FINAL y f VALIDATION fect. c HOSE BIB DATE Z( a License Number �'��Z J44,1.1c. Class C Z 7 _ _ _ C� 0 FINAL 0 C) Contractor �� 6� Date f ! BY RCTo4 ❑ I am exempt under sec. L3303 43040? B.&P.C. for this reason Plan check fee ® 1 ITEMS w Date: PLUMBING PERMIT ISSUING FEE$ v TOTAL 43.3 o&j.-0� Signature TOTAL FEE MZC;"1 43.4x,' SINGLE FAMILY Plan check applicant CHANGE .00 HOME OWNER-BUILDER DECLARATION pp I hereby affirm that 1 am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and Professions Code): Address QOOMMI 3/ 5/96 ❑ 1, as owner of the property, will do the work and the City Tel. No. 5142 1 P,112:45 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 X Sig of Permittee Date