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Home My Public Portal About6537 OAK AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof(Sec: 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No..� —Company 'flG.��°' ❑ Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS C Certified copy is filed with t e county building inspec- VW NUMBER FIXTURE OR ITEM tion department. � FEE LOCALITY �) �✓ Date. `� � Appli4ux) i WATER CLOSET NEAREST E CERTIFICATE OF EXEMPTION OM WORKERS' + BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL or) the permit is for one hundred dollars($100)or less.) I LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner i SINK CITY TEL.NO. so as to become subject to the Workers'Compensation Laws. I DISHWASHER CONTRACTOR I Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: if, after making this Certificatd of Exemption, you should become subject to the Workers' 1 SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- I LAWN SPRINKLER SYSTEM CITY TEL. NO. .. with comply with such provisions or this permit shall be STATELIC. deemed revoked. J WATER HEATER LICENSE NO. 1 CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED BY I hereby:affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000)of Division 3 of the Business1 OUTLETS OVER � and Professions Code,and my license is in full force and effect. + 5 PER SYSTEM FINAL VALIDATION 0 LicenseiNumber ! Lic. Class J6 6 4 DATE FINAL Contract Date BY' ty Iam exempt under Sec. #A B.BP.C. for this reason r d-9 Plan check fee ' Date: PLUMBING PERMIT ISSUING FEE$ Signature p d ` TOTAL FEE p In Plan check applicant ! '� SINGLE FAMILY CI 1 3 3 A HOME OWNER-BUILDER DECLARATION 1 Name I hereby affirm that I am exempt from the Contractor's License P c'o o o a 5 Address Low for the following reason (Section 7031.5, Business and C,' 2 0'c 3 0,50 Professions Code): I City Tel. No. o'0"o 3` 5 9 ❑ I, as owner of the property, will do the work and the I ; —8 LL r structure is not intended or offered for sale (Section j 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 i 4ahir nd State laws regulating Plumbing, and hereby presentatives of his County to enter upon the ` oned proper r inspection purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE �— Permittee Date I ` WORKERS'COMPENSATION DECLARATION APP OCA` NDN FOR PLUMBING n UMBI G PERM 17 I here 20-0026 DPW 4/87 E6 LI l!—LU fJWYGI tf�] I� ®Fh'11 fay, q€firrr�that I have a certificate of consent to self in- 76A667A sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86) certified copy Thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company. Certified copy is hereby furnished. O� ' FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM @ FEE ADDRESS department. LOCALITY Date Applicant WATER CLOSET(TOILET) NEAREST BATH TUB CROSS S7. 6XI E��//,,,��y� /� CERTIFICATE OF EXEMPTION FROM.WORKERS' BA //A , COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL �,�// the permit is for one hundred dollars($100)or less.) LAVATORY DRESS �3 7 OV z d.4e ./� V� I certify that in the performance of the work for which this per- SINK / mit is issued, I shall not employ any person in any manner so CITY 7G ag- Coir/ TEL. NO as to becom subject to the Workers' pens io La GG r 4 / DISHWASHER /� AVI-u�13/d,� 9 /, �A CONTRACTOR �i ,V Date ` v Applicant CLOTHES WASHER 0 ADDRESS NOTICE APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- �-� CITY sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM TEL. NO.:? � ly with such provisions or this permit shall be deemed revok- STATE p/ LIC. �y ed. WATER HEATER LICENSE NO. p/ CLASS (:— LICENSED CONTRACTORS DECLARATION DISTRICT NO. P SED B 1 hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM f OUTLETS ® 0 9(commencing With Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5/PER SYSTEM ��y� FINAL �� VA DATIOYV >' fect. p// /u 7�1 DATE t L '`�rJ CL O License Number &1 L1c. Class— V ,��// �j FINAL �� Q Contractor R gA(&gd-Date BY '�f _ O I am exempt under Sec. W _.I r B.BP.C: for this reason i ° of Plan check fee — Date: PLUMBING PERMIT ISSUING FEE$ Signature �D TOTAL FEE SINGLE FAMILY .01.& 45 _ 6.0 HOME OWNER-BUILDER DECLARATION Plan check applicant ,,, i-j. - I hereby affirm that I am exempt from the Contractor's License Name CHECK 45.h Law for the following reason (Section 7031.5, Business and C, hi;;F .2ju Professions Code): Address F] 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, 09013-900 i 7' 3[J i Business and Professions Code). `77 AM . .`7 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 D ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the Bove- oned op e for' pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign f e of Permittee Date KGEERMIT op 617(REV.6/78)APPLICA IONRPLUM COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING i NUMBER' FIXTURE OR ITEM ® FEE ADDRESS WATER CLOSET LOCALITY 4� NEAREST BATH TUB CROSS ST. SHOWER OWNE LAVATORY MAIL ' ADDRESS /� N SINK CITY'. DISHWASHER �L 'CONT CLOTHES WASHER ADDR / + d Lid✓ SWIMMING POOL RECEPTOR . CITY �� TEL LAWN SPRINKLER SYSTEM STATE LIC. / WATER HEATER LICENSE NO. '� CLASS 4� GAS SYSTEM OUTLETS - APPROVALS DATE INSPECTOR'S SIGNATURE OUTLETS'OVER UNDER SLAB WORK 5 PER SYSTEM ROUGH PLUMBING GAS PIPING v HOT WATER.HEATER V PLUMBING FIXTURES 9 GAS TEST Plan Check,fee UTILITY CO.NOTIFIED PLUMBING PERMIT ISSUING FEE$ TOTAL FEE o Plan check applicant PLAN CHECK A:LIDATIO Q Name Address City Tel.NO. �O�fiOA I THEREBY ACKNOWLEDGE THAT I HAVE READ•THIS APPLICATION AND STATE .4 O CIO o O F THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING. PERMIT VALIDATION 2 O - 40,00 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE - O O 0 It 0.0 C U LEGAL OWNER OF.AND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. 0 Ek-0 U a— Q U 0 SIGNATURE l/ OF PERMITTEE r L PROC SED BY . INDUSTRIAL WASTE APPROVAL