HomeMy Public PortalAbout10209 OLIVE ST_Plumbing__ WORKER'S COMPENSATION DECLARATION SA867APW9/99 APPLICATION FOR PLUMBING PERMIT
I herebX affirm that.I have a certificate of consent to self Insure, ,
or'a certiffcatp of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No. Company
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS a1.I eL Q.!(•tA/� �^
❑ Certified copy is filed with the county building Inspection
department. NUMBER FIXTURE OR ITEM ® FEE
LOCALITY
Date Applicant a WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE BATH TUB ASSESSOR
(This section need not be completed If the work Involved by the SHOWER MAPBOOK PAGE PARCE
permit Is for one hundred dollars($100)or less.) Q OWNER
I certify that in the performance of the work for which this permit 0. LAVATORY
Is Issued, I shall not employ any person in any manner so as to ` SINK ADDRESS �(5 .
become subject to the Workers'Compensation Laws.
t DISWASHER CITY TEL. O., f,l,(f 3.00]
Date Applicant t CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, -
you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS 1. Or:..�5 •f �oTt....
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked, LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY ' T{�'-r �a (�3-007 a
1 hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER /� LfCC����
(commencing with Section 7000)of Division 3 of the Business and 1 GAS SYSTEM OUTLETS IL CENSE NO. � 7 T CrkSS`J 1°,�.1" (O]
Professions Code,and my license Is In full force and effect. Eb DISTRICT NO. PROCE I '^
OUTLETS OVER � •- -
License Number a.3 *7 4 1 Lic.Class C' 395 PER SYSTEM ��� 60 Q
t , �(2-�
FINAL t 23{{ V
+ DATE 3-g� VA1t11TION :: LaZr1 a
Contractor Date FINAL ('HANGE °01.3 M
❑ I am exempt under Sec. 1BY
B.&P.C.for this reason
Plan check fee , 01 00-110tH 2 /95
Date:
PLUMBING PERMIT ISSUING FEE$ dZ� 9014 1 AM 91:0
Signature
❑ TOTAL FEE 3/ Q
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Address
Code-
City Tel.No.
1 1,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
i
Lender's Address
I certify that I have read this application and state that the above Pol-
and
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
pro rty inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
-T-0-9,1995
Cin fnro of Porminaa Date
WORKER'S COMPENSATION DECLARATION ;MG67A PW 9,99 APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I 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.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No. Company
❑ Certified copy is hereby furnished. BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy Is filed with the county building inspection
department. NUMBER FIXTURE OR REM @ FEE LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE ASSESSOR Q
(This section need not be completed If the work involved by the SHOWER MAP BOOK v.5W. PAGEQD/ PARCEL
permit is for one hundred dollars($100)or less.) OWNER
I certify that in the performance of the work for which this permit' LAVATORY
Is issued, I shall not employ any person in any manner so as toSINK ADDRESS �p 5
become subject to the Workers'Compensation Laws.
DISWASHER CITY TEL.NO. 3 O
Date Applicant CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall,be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSEDCONTRACTORSDECLARATION CITY TEL.NO. }
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS CENSE NO. CLASS
Professions Code,and my license is in full force and effect.
OUTLETS OVER DISTRICT NO. PROCESSED BY �
5 PER SYSTEM �x
License Number Lie.Class u
6 FINAL VALIDATION a
DATE
Contractor Date cc
E] I am exempt under Sec. BY AL -
&y I B.&P.C.for this reason `3 {:� 1111.3•`
Plan check fee 111
Signature Date. PLUMBING PERMIT ISSUING FEE$ �• �,� , 1 !1 tS
} TOTAL FEE156
TOTAL 1121 ®'
❑ Plan check applicant , 'CHEEC'` 121.35
SINGLE FAMILY G�
HOME OWNER-BUILDER DECLARATION Name CHANGE
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5, Business and Professions Address
Code): ►113010-131 01 3/??/915
City Tel.No.
5KI,as owner of the property,will do the work and the structure ' c •
is not intended or offered for sale(Section 7044, Business
and
9!21
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-mentloned
proa ty f inspection purposes.' SEE REVERSE FOR EXPLANATORY LANGUAGE
F
3-aa-�5
Cin nra of DermiMoo Data