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Home My Public Portal About5708 NOEL DR_Plumbing__ c wOR1RSCOMPENSATION DECLARATION 7 DP►^►91� APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to elf insure or a certiTicate of Worker s Compensation Inayga r B certified I copy thereof(Sec 3800 Lab C) h COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV li Policy No Co - ❑ Certified copy is furnished FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ❑ ADDRESS CertiO is filed with the county building inspection O d ant NUMBER FOCTURE OR ITEM ® FEE( LOCALITY Da Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERSCROSS ST BATH TUB ASSESSOR COMPENSATION INSURANCE MAP BOOK LAI PAGE PARCEL (This section need not be completed If the work Involved by the SHOWER permit Is for one hundred dollars(=100)or less) LAVATORY OWNER 1 certify that in the performance of the work for which this permit MAIL is issued I shall not employ any persoany manner so as to SINK ADDRESS become subj t to the Workers Compen do Laws l DISWASHER CITY TEL NO Date Applicant r4 1 CLOTHES WASHER NOTICE APPLICANT If after eking this Certificate of CONTRACTOR 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 d 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 LICA NE SE NO LI CASS 8 Professions Code and my license is in full force and eff OUTLETS OVER DISTRICT NO PROCESSED BY Q 5 PER SYSTEM 0 License Number Li ass W DA VAUDa#10N Conn. IIgactor Date _ �a Z LpJ I am exempt r Sec / BY FINAL _30 t 1 i rE193 B&P this reason Dam Plan check fee 101 A- 88 ® 20 PLUMBING PERMIT ISSUING FEE$ G , CHEiY OvJ i I Signature O t RANGE GO 1:1 TOTAL FEE f SINGLE FAMILY Plan Check applicant ` HOME OWNER BUILDER DECLARATION Name I 0000-00O 1 .r�,it S-4 1 hereby affirm that I am exempt from the Contractor s License Law f0is he following reason(Section 7031 5 Business and Professions Address Q VA tJ1 AM S City-17 Tel No I as owner of the property will do the work and the structure not intended or offered for sale(Section 7044 Business and Professions Code) , CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction landin ency for the performance of the work for which this permit sued(Sec 3097 Civ.C) Lender s Name Lender s Address ` I certify that I have d this application and state that the above ► information is co t I agree to comply with all County ordinances and State law regulating Plumbing and hereby authorize representativ s of this County to enter upon the above mentioned prop. to nspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Z Signature of Perfnittee bate WORKERS COMPENSATION DECLARATION 76Aa67A I hereby affirm that I have a certificate of consent to self Q6 617(2 ire) APPLICATION FOR PLUMBING PERMIT insure or a certificate of Workers Compensation Insurance or a-catr ed copy hereof(Sec 3800 L b C II/ ) ��u/+ � COUNTY OF LOS ANGELES � + BUILDING AND SAFETY Policy o Company Certified copy is hereby furnished FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING J� Certified copy a filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE ADDRESS LOCALITY WATER p �,®„�, WATER CLOSET Dste�Applicant�C ��_ NEAREST BATH TUB CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE Y. SHOWER 421OWNER MAIL (Thus section need not be completed if the work involved LAVATORY ADDRESS d43 IL by the permit >8 for one hundred dollars ($100) or less) SINK CITY Gl{� TEL NO V I certify that in the performance of the work for which this DISHWASHERt>C permit as issued I shall not employ any person in any manner i// CONTRACTOR so as to become subject to the Workers Compensation Laws CLOTHES WASHER ADDRESS Date Applicant d SWIMMING POOL RECEPTOR NOTICE TO APPLICANT If after making this Certificate of CITY TEL NO CO) Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE LIC Compensation provisions of the Labor Code you must forth WATER HEATER LICENSE NO CLASS with comply with such provisions or this permit shall be deemed revoked GAS SYSTEM OUTLETS DISTR,crNo PR ESSED LICENSED CONTRACTORS DECLARATION OUTLETS OVER 's',o� I hereby affirm that I am licensed under provisions of Chapter 6 PER SYSTEM 1 9 (commencing with Section 7000)of Division 3 of the Buse FINAL VALIDATION ness and Professions Code and my license is in full force and DATE —'L—S�. effect FINA \ License Number Lic Class BY Contractor Date I am exempt from the licensing requirements as 1 am a Pian check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ (� acting in my professional capacity (Section 7051 Bus mess and Professions Code) TOTAL FEE 0 S� Lic or Reg No Date Plan check applicant HOME OWNER BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractors Address License Law for the following reason (Section 7031 5 Busy Icity Tel No n and Professions Code) I as owner of the property am exclusively contracting -V261 0 P with licensed contractors to construct the project (Section 7044 Business and Professions Code) # a a a a a 51 CONSTRUCTION LENDING AGENCY 2 - 4060 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is a a 04 0 5-0 issued(Sec 3097 Civ C) Lender a Name 01 13-82 Lender a Address I certify that I have read this application and state that the above information is correct I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing and hereby authorize representatives of this County to enter upon the ab a mentioned property for inspection purposes lP Signal a of Permittee Dat