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Home My Public Portal About5915-5927 OAK AVE_Plumbing__ WORKERS COMPENSATION DECLARATION 20-OM DPW 4,90 APPLICATION FOR PLUMBING PERMIT Ikereby affirm that I have a certificate of consent to self m 76A667A � sure or a certificate of Workers Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS E] Certified copy is hereby furnished FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING /S a� rl Certified copy is fled with the county budding in eetion ADDRESS J department ,�r`► NUMBER FIXTURE OR ITEM ® FEE LOCALITY pate WATER CLOSET(OILET) Piicant QST"— Ap CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST Q S COMPENSATION INSURANCE SHOWER OWNER -Qcat (This section need not be completed If the work Involved by MAIL p the permit Is for one hundred dollars($100)or less) LAVATORY ADDRESS V- — 1 certify that in the performance of the work for which this per SINKCITY TEL NO mit is issued I shall not employ any person In any manner so as to become subject to th Workers Compensation Laws DISHWASHER _ CONTRACTOR Date Applicant CLOTHES WASHER NOTICE TO APPLICANT If after making this Certificate of Ex ADDRESS emption you should become sub ect to the Workers Compen SWIMMING POOL RECEPTOR �t code CRY IsTEL '{ sation provisions of the Labor a you must forthwith comp LAWN SPRINKLER SYSTEMS Ic ly with such provisions or this permit shall be deemed revok STATE O uCC ed WATER HEATER 1 .9 LICENSED CONTRACTORS DECLARATION / DISTRICT NO PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �� 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code and my license is in full force and of 5 PER SYSTEM FINAL / VALIDATION fact HOSE BIB DATE a5'2°5 C License Number Lic Class— ITMS ZZ35 a FINAL � _� 0 Contractor Date BY (HECK 58.39 OC I am exempt under SecCHIWE .00 S&P C for this reason Plan check fee Date PLUMBING PERMIT ISSUING FEE$ 0000—OMI 9/ 3/99 Signature TOTAL FEE 0284 1 F" 5.39 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 Professions Code) Address 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 ordmans and State laws regulating Plumbing and hereby author presentatry of this County to enter upon the above coned pro for inspection pur SEE REVERSE FOR EXPLANATORY LANGUAGE Signatur ermi Date ION WORKER I have of consent to 7 D�N91� APPLICATION FOR PLUMBING PERMIT I'hereby affirm that 1 have a certificate of consent to self insure or a certificate of Worker's Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) Company �+��'-� F � COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS k DEPT OF PUBLIC WORKS DIV Pol NoCertified copy a1 hereby fumeW FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADIIENG / s/lr ❑ Certified copy M filed with the county building Inspection ®G pwtment NUMBER FIXTURE OR ITEM ® FEE LOCALITY oro `c— G, Date 7 Applicant WATER CLOSET CERTIFICATE OF EXEMPTI FROM WORKERS CROSS ST /v COMPENSATION INSURANCE BATH TUBASSESSOR (This section need not be completed if the work Involved by the # SHOWER MAP BOOK I PAGE PARCEL permit Is for one hundred dollars($100)or low) LAVATORY OWNER I certify that In the performance of the work for which this permit MAIL is issued I shall not employ any person in any manner so as to SINK G ADDRESS / �� become subject to the Workers Compensation Laws DISWASHER CITY `. TEL NO 9 Date o l TO APPL CANf efts making t Certificate of CLOTHES WASHER CONTRACTOR SASH ,41�1� Exemption you should become subjectto the Workers Compensation SWIMMING POOL RECEPTOR ADDRESS provisions of the Labor Code you must forthwith comply with such provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL NO 3 I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER /' (commencing with Section 7000)of Division 3 of the Buame$a and GAS SYSTEM OUTLETS LICENSE NO -40-f.10-6 Z— CU AS8 Professions Code and my license is In full force and effect OUTLETS OVER DISTRICT NO PROCESSED BY cc 5 PER SYSTEM �� 0 License Number_/2 d LIC Class E_ FINAL DATE ' V IDATION W Contractor.�� & Date FINAL I+r g E] I am exempt under Sec BY33343 72.7� f■s Z B aP C for this reason Date Plan check fee ► 1 ITEMS Signature PLUMBING PERMIT ISSUING FEE$ .?4 7 TATA. 72.75 ❑ TOTAL FEE MCK 72.r SINGLE FAMILY Plan check applicant Id>rua .134 HOME OWNER BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractors License Law for the following reason(Section 7031 S Business and Professions Address Code) ❑ City Tel No 1 1 AM 9;12 I es 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 Pol.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 prope r ins p on purpo9 SEE REVERSE FOR EXPLANATORY LANGUAGE S( ature of Permittee Date t`dORKERSCOMPENSATION DECLARATION 2D4=DPW 9189 APPLICATION FOR PLUMBING PERMIT a 78A987A I�he'�eby a irm tli8t I leve a certificate of consent to self Insure or a certificate o`f Worker s Compensation Insurance or a certified . &py thgreof(Sec 9800 Lab C) Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV .❑ Ce N d copy 1,hereby fumiahed FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ❑ Cenifled copy is bAD led Mh the county building inspaquin LOCALITY �O?' �V depart ent `' NUMBER FIXTURE OR ITEM FEE Data Applicant WATER CL08ETN V Moss sr CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB //�� COMPENSATION INSURANCE jAAP� PAGE CO 7 PARCEC`r (This section need not be completed If the work Involved by the SHOWER permit Is for one hundred dollars($100)or less) LAVATORY OWNER //7 1 certify that in the performance of the work for which this permit is issueMAIL d I shall not employ any person in any manner so as to SINK ADDRESS 16 /f become subject to the Workers Compensation Laws DISWASHER CITY SC TEL NO Date Applicant NOTICE TO APPLICANT If after making this Certificate of CLOTHES WASHER CONTRACTOR Exemption you should become subject to the Workers Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITYTEL NO I hereby affirm that 1 am licensed under provisions of Chhapter 9 WATER HEATER �%�►'�. /�c�- (commencing with Section 7000)of Division 9 of the Businbss and GAS SYSTEM OUTLETS LICENSE NO Q L C Professions Code and my license is in full force and effect CLASS 34 OUTLETS OVER DISTRICT NO PROCESSED BY /o/40J79 .3G b PER SYSTEM 0 License Number LIC Class FINALd contractor 9d s (.t VALIDATION Wa ❑ Pal 1 am exempt under Sec Bif 57 Do DATE y _307 +r 19.9U Z B AP C for this reason I ITEMS Plan check fee Date Signature PLUMBING PERMIT ISSUING FEE$ 1113 poll. 215-50 ❑ TOTAL FEE CHECK 215-W SINGLE FAMILY Plan check applicant ,u0 HOME OWNER BUILDER DECLARATION Name 4&el�8 �7 I hereby affirm that I am exempt from the Contractor a License Law t�c� n r for the following reason(Section 7091 S Business and Professions Address `j �� 0000-MOI 121 17r 9f) Code) City Tel No f/0-"7-7 /t 1 F M 12 i 51 ❑ I es 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 9097 Civ C) Lender a Name Lender s Address 1 certify that I have read this application #d 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