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Home My Public Portal About6396 OAK AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 7BA655DPw9l89 APPLICATION FOR PLUMBING PERMIT 1 hereby.affitm that I have a certificate of consent to,self insure, 70A567A or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) Policy No. Company COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. 0 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING I Certified copy is filed with the county building inspection ADDRESS fy department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET NEARESTi eq �b BATH TUB CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. L. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK 3 Z, PAGE Q/ PARCEL014 permit is for one hundred dollars($100)or less.) OWNERCA6a L ffi155r Q I certify that in the performance of the work for which this permit MAIL LAVATORY Is issued, I shall not employ any person in any manner so as to SINK ADDRESS become subject to the Workers'Compensation Laws. DISWASHER CITY TEL.NO. a 00 L Date Applicant CLOTHES WASHERv s� NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS provisions of the Labor Code,you,must forthwith comply with such provisions or this permit shall.be deemed revoked.. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATIONCITY TEL.NO. I hereby affirm that I'am licensed under provisions of Chapter 9 WATER HEATER /LI �, 0. (commencing with Section.7000)of Division 9 of the Business and LICE SE NO. CLASS TE LIC. 0 Professions Code,and my license is in full force.and effect. GAS SYSTEM OUTLETS OUTLETS OVER DISTRICT NO. PR Y 5 PER SYSTEM License Number Lic.Class Q F- ' ' FINAL DATE "LIDA ION LLI Contractor Date 44S El I am exempt under Sec. BY �� ACCT A 1� 3307 6".40 B.&P.C.for this reason a Plan check fee Poo. ITEf1S Date: Signature PLUMBING PERMIT ISSUING FEE$, .y 76- TOTAL ' 68.40 ❑ TOTAL FEE CH4CY, 68.40 SINGLE FAMILY Plan check'applicant CHANE .00 HOME OWNER-BUILDER DECLARATION Name A POR LSS(O aa I hereby affirm that.I am exempt.from the Contractor's License Law ry for the following reason(Section 7031.5, Business and Professions Address 3.l Q �y � _��1-y /19/ Code):. -�• se� V- to , city Tel.No. 7686 1 AM 9:36 I,as 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 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 propert r' spectia purp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE 'affinature of ermlttee V to 76AG67A WE 81719)-11/76 APPLICATION FOR PLUMBING PERMIT BUILDING AND SAFETY DIVISION FOR APPLICANT TO FILL IN(PRINT OR TYPEI BUILDING ' [� .� NUMBER FIXTURE OR ITEM FEE ADDRESS Ga !6 A g9k� A VO 'a WATER CLOSET 3 LOCALITY eA NEAREST BATH TUB CROSS ST. SHOWER OWNER ! 64 Z Ae LAVATORY dv ADDRESS ZX46 AFAIRMA16~ SINK 6- 0 CITY ,4 Q TEL.NO.N41_ Q DISHWASHER 0(� CONTRACTOR CLOTHES WASHER ADDRESS ICE �C SWIMMING POOL RECEPTOR CITY L r AE TEL.N0.7C?� �Q�ty AWN SPRINKLER SYSTEM T STATE LIC. WATER HEATER 3 L� LICENSE NO:3J?.q'D CLASS C " 3jG GAS SYSTEM 3 OUTLETS 3 �� DISTRINO. GRO UP Z E PRO ESS D I OUTLETS OVER G;08 I- 5 —5 PER SYSTEM INDUSTRIAL WASTE APPROVAL INSPECTION RECORD in IL in z Plan check fee PLUMBING PERMIT ISSUING FEE$ TOTAL FEE yL Plan check applicant APPROVALS DATE INSPUI-OR'S SIGNATURE Name UNDER SLAB WORK Address ROUGH PLUMBING City Tel.No. GAS PIPING I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE GAS VENT THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING. HOT WATER HEATER I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANGOR LICENSED AS PLUMBING FIXTURES REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE GAS TEST /2 L OWNER OF.AND INT RESIDE IN THE ABOVE SCRIBED RESIDENTIALRT ,( UTILITY CO..NOTIFIEDOW&VO �`✓0 ATUREERMITTEE FINAL PLAN C EC ALIDATION CK. M.O. CASH PERMIT VALIDATIONCK. M.O. CASH S 3 t-AUG 12 5 D 3 4.5 0 Md POLICY HOLDER: ®f