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Home My Public Portal About10621 OLIVE ST_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I heT�by,laffitrq that I have a certificafe of Co`nsen't to'self in- X20-0026 DPW 4/90 �i� �ke/'1 PERMIT sure,or a cortificate of Workers'Compensation Insurance,or a 76A667A certified topy tkereof(Sec. 31800, Lab. C.) Folicy4 C01npanyErEMo_I__ _i' &M. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ❑ Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) IQI Certified copy is filed with the county building inspection ADDRESS �J department. NUMBER FIXTURE OR ITEM @ FEE � LOCALITY O Ddte 5-c;10-75 Applicant VIM/ 3 WATER CLOSET(TOILET) NEAREST • qq�� CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. lei COMPENSATION INSURANCE SHOWER OWNE= (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS �' aVn I certify that in the performance the work for which this per- SINK / � CITY G mit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. DISHWASHER ,°;V_ � CONTRACTOR Date Applicant CLOTHES WASHER , �, ADDRESS NOTICE TO APPLICANT: if, after making this Certificate of Ex- SWIMMING POOL RECEPTOR &E, emption,you should become subject to the Workers'Compen- sation provisions of the Lobar Code,you must LAWN SPRINKLER SYSTEMS forthwith comp- CITY , nfe TE .ffi) 337 ly with such provisions or this permit shall be deemed revok- STATE �! CLASS ed. WATER HEATER LICENSE NO. c� LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSEb BY I hereby affirm that I am licensed.under provisions of Chapter •GAS SYSTEM OUTLETS J el 9(commencing with Section 7000)of Division 3 of the.Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL /ALIDATION fect. eD HOSE BIB DATE License Number f&' Lic. Class v� 7' :4 f °s C _.,_M P166, 6 ��`9� FINAL Y Contractor Y Date i BY 'i1,.', I am exempt under Sec. D T.i E 11= O B.BP.C. for this reason �), � ��s a ;6((..0 W Plan check fee } ` a Dare: PLUMBING PERMIT ISSUING FEE$ �' J C'•H*.'CK -'=`'°WJ Z TOTAL FEE 'C '�Sl�.jf Signature O E t j=__• - 4_; SINGLE FAMILY applicant Plan check a HOME OWNER-BUILDER DECLARATION PP• _ I hereby affirm that I am exempt from the Contractor's LicenseName t if'i_i'-r)t i l j �y i }'•_'!'?_-` Law for the following reason (Section 7031.5, Business and O, •M� �7�s'h Professions Code): Address ��tiO 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, 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 abov m tinned op r}y for inspection purposes. L, 10 7S SEE REVERSE FOR EXPLANATORY LANGUAGE Sig re of Pe i ee Date WORKERS'COMPENSATION DECLARATION 20-0026 DPW 4/90 APPLICATION FOR PLUMBING PERMIT I hereby, affirm that I have a certificate of consent to self in sure,or a certificate of Workers'Compensation Insurance,or a 76A667A cerWi�pd o thereof(Sec. 3800, L. C.) dull PolicNyNo��. o�%— �` Company �1�►� 13 d � COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Certified copy is hereby furnished. -,/—/— BUILDING _ FOR APPLICANT TO FILL IN(PRINT OR TYPE) Certified copy is filed with the county uildin i p tion ADDRESS Q 6 z/I U d�jep rime .. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date L �� L' Applicant WATER CLOSET(TOILET) NEAREST CERTIf KATE OF EXEMPTION FROM WOR RS' BATH TUB CROSS ST. 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 ADDRESS I certify that in the performance of the work for which this per- SINK CITY TEL. NO. mit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. DISHWASHER 1 i CONTRACTOR LA fdM Date. Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS r SWIMMING POOL RECEPTOR A" tion,you should become subject en- ��— em ect to the Workers'Com pen-Y I P CITY - TEL. NO.AS l sation provisions of The Labor Code,you must forthwith comp- 3 LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE ��..� LIC. ed. WATER HEATER LICENSE NO. ,. �j J CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NPROCESSEb BY O. G I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ` e 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 FINAL VALIDATION fect. S33S - G'�- HOSE BIB DATE LO-Z License Number Lic. Class C � L 4/ FINAL C7 Contractor e D BY � I am exempt under Sec. 5 C0 ~7 B.&P.C. for this reasonPlan check fee ► ACCT.-uma Date: PLUMBING PERMIT ISSUING FEE$ .3303 75.60 a Signature TOTAL FEE1 ITEMS SINGLE FAMILY TOTAL 75 o 60 HOME OWNER-BUILDER DECLARATION Plan check applicant CHECK 75.60 1 hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and CHANGE 00 Professions Code): Address ❑ 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, 0000—(MO1 9/25/95 Business and Professions Code). 2470 1 Ph 4:53 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 correc ree to comply with all County ordinances and State law reg lating Plumbing, and hereby authori a ntati kf11 County to nter upon the ab ve- ned proppection ur oses. 416, SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permitt a Dat