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Home My Public Portal About5332 NOEL DR_Plumbing__ WORKERS COMPENSATION DECLARATION 20-M DPW 4,90 APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self in 76A667A sure or a certificate of Workers Compensation Insurance or a [� certified copy thereof(Sec 3800 Lab C) U Policy No._Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS derhfied copy is hereby furnished BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) Certified copy is filed with the county building inspection ADDRESS e2lRleA department NUMBER FIXTURE OR ITEM @ FEE LOCALITY Dote Applicant WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST COMPENSATION INSURANCE OWNER SHOWER (This section need not be completed if the work involved by MAIL the permit Is for one hundred dollars($100)or less) LAVATORY ADDRESS I certify that in the performance of the work for which this per SINK CITY TEL NO mit is issued I shall not employ any person in any manner asto beco a sub ct to the Workers Co pensasti�on La DISHWASHER CONTRACTORj�ar �G r P/Date 4f`—� Applicant / CLOTHES WASHER ADDRESS NOTFCf TO APPLICANT If after making this Certificate SWIMMING POOL RECEPTOR emption you should become sublect to the Workers Compere CITY / sation provisions of the Labor Code you must forthwith comp LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok STATE LIC ed WATER HEATER LICENSE NO CLASS LICENSED CONTRACTORS DECLARATION GAS SYSTEM OUTLETS /O DISTRICT NO PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter -�v 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER Q and Professions Code and my license is in full force and of 5 PER SYSTEM FINAL VALIDATION fect A�714.9 HOSE BIB DATE )0, License Numbe Lic Cla IL FINAL 0 Contracto Date BY 0 ❑ I am ex mpt under Sec S&P C for this reason ► ACCT * W Plan check fee Dat PLUMBING PERMIT ISSUING FEE$ U ITE!` 3 z_ Signature TOTAL FEE SINGLE FAMILY j0p, Plan check applicant HOME OWNER BUILDER DECLARATION PP 0OW-0001 7I12►1;` 1 hereby affirm that I am exempt from the Contractor s License Name Law for the following reason (Section 7031 5 Business and - 1287 1 Q{"(11 z!) Professions Code) Address 13 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 s 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 Jhis County to enter Pon the above ntioned propertyinspec on purpos ��/ SEE REVERSE FOR EXPLANATORY LANGUAGE 1oature of Permittee Date WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that J have a certificate of consent to self an 7DPW 4/90 A sure or a certificate of Workers Compensation Insurance or a n certified copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGELES DEPT OF OUBLIC WORKS. U Policy No Company Certified copy is hereby furnished ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESS 3�Z N DEZ ! A'I department NUMBER FIXTURE OR ITEM ® FEE LOCALITY / WATER CLOSET(TOILET) Dote Applicant A NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST Or COMPENSATION INSURANCE SHOWER ER (This section need not be completed If the work involved by MAIL the permit is for one hundred dollars($100)or less) LAVATORY ADDRESS I certify that in the performance of the work for which this per SINK CITY TEl NO mat is issued I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws DISHWASHER CONTRACTOR z/flys- x W J*!67-0 �L Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT If after making this Certificate of Ex SWIMMING POOL RECEPTOR emption you should become subject to the Workers Compen CITY TEL NO sation provisions of the Labor Code you must forthwith comp LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok STATE LIC ed WATER HEATER LICENSE NO CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS n y 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER v and Professions Code and my license is in full force and of 5 PER SYSTEM FINAL VALIDATION fect HOSE BIB DATE License Number Lac Class C FINAL ry V Contractor Date BY 14CE] 1 am exempt under Sec �� s Q OW B&P C for this reason Plan check fee ► 301�1 3rW 1 ITEMS ILGo Date PLUMBING PERMIT ISSUING FEE$ ��j TIITAL. 1 �,a�, -50 Signature TOTAL FEE /. CHECK t 12 1 Sry SINGLE FAMILY HOME OWNER BUILDER DECLARATION Plan check applicant CHANGE DO I hereby affirm that I am exempt from the Contractor s License Name e10K GAJ ATO Law for the following reason (Section 7031 5 Business and Professions Code) Address L.332 VELice(? 0000_0001 9/ 2/99 I as owner of the property will do the work and the City TEAim= C r Tel No 818' ,2—7416 0.44 1 AM 9 22 structure is not intended or offered for sale(Section 7044 Business and Professions Code) ► CONSTRUCTION LENDING AGENCY I hereby off arm 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 t 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 amhorize rIlpresentatives of this County to enter upon the Mtn erty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o Permittee Date