HomeMy Public PortalAbout10158 OLIVE ST_Plumbing__ 1 W�shat r COMPENSATION a certificate
of consent to gg687APw9,e9 APPUCATI®N FOR PLUG MIG PERMIT
I hereby�effirm i:ha?�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.)
Policy No. Company COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
❑ Certified copy is hereby furnished. ��
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �
copy is filed with the county building inspection ADDRESS ' e o l
Certified co .
department. NUMBER FIXTURE OR ITEM ® FEE LOCALITY
Date ApplicantWATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE ASSESSOR r/�p�r"' •
(This section need not be completed if the work involved by the SHOWER MAP BOOK O O✓ PAGE 49,;L PARCELO/7
permit Is for one hundred dollars($100)or less.) OWNER
I certify that in the performance of the work for which this permit 2— LAVATORY
is issued, I shall not employ any person in any manner so as toMAIL
i
become subject to the Workers'Compensation Laws. SINK ADDRESS 161 Ive
DISWASHERCITY % TEL.NO.� 01--// fir
Date Applicant CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION ` WATER HEATER CITY TEL.NO. A.>
I hereby affirm that I am licensed under provisions of Chapter 9 `
(commencing with Section 7000)of Division 3 of the Business and STATE LIC.GAS SYSTEM OUTLETS LICENSE NO. CLASS C
Professions Code,and my license Is in full force and effect.
OUTLETS OVER DISTRICT NO. PROCESSED BY Ix
5 PER SYSTEM �i�' l�G
License Number Lic.Class lJ
FINAL _
DATE VALIDATION �
Contractor Date Cr
❑ FINAL c 2
am exempt under Sec. BY —&
n^•f c
B.&P.C.for this reason
Plan check fee
Date: �� _•L:( � Y�,._c,
PLUMBING PERMIT ISSUING FEE$
Signature R
s 4 ITEM,
❑ TOTAL FEE �
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name D.
1 hereby affirm that I am exempt from the Contractor's License Law ''I•-'NGE
for the following reason(Section 7031.5, Business and Professions Address
Code):
❑
I,as owner of the property,will do the work and the structure City Tel.No. [;,I��—�)tit�l� �1 f•��a/f;.;;
is not intended or offered for sale(Section 7044, Business f
and Professions Code). _ AMS�t,,.;::y,�r
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
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE