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Home My Public Portal About9207 OLIVE ST_Plumbing__ TWORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT °OIrm that I have a certificate of consent to self in-. ,20;0.026 DPW 4/87• 76A667A 1 `su too� :ertificate.of Workers'Compensation Insur•.ance,ora CE 817(REV.8%86) certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT, OF PUBLIC WORKS . v Policy No. R:Company p y ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING. �j'' O�� F-1Certified copy is filed with the county building inspection NUMBER FIXTURE.OR.ITEM ADDRESS L � department. @ FEE _ LOCALITYL� (✓l�, Date Applicant WATER CLOSET.,(TOILET) NEAREST. ' [ , • CERTIFICATE OF EXEMPTION FROM.WORKERS' BATHTUB CROSS ST. , AJR, COMPENSATION INSURANCE -SHOWER OWNER ; w' (This section need not be completed if the work involved by MAIL 'f��fN'V`S /vGim the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESSX. / DRESS 'a? oG 6 U 517 I certify that in the performance of the work for which this per- SINK ITY L TEL. NO q�- mit is issued, I shall not employ any on i' manner so661 � Cir19-- as to become subject to the V1lor s'Co ensati n Laws: DISHWASHER t1�, g s t P7 ' - •, CONTRACTOR l— _ Date Applicant CLOTHES WASHER ADDRESS NOTICE O APPLICANT: If, after making this Certificate of E SWIMMING POOi RECEPTOR e'mption,you should become subject to the Workers'Comp CITY TEL. NO. sat(on provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM ly with-such provisions or this permit shalt be.deemed revok- STATE LIC. ed. WATER HEATER ICENSENO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS D n 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER a and Professions Code, and my license is in full force and ef- 5 PER.SYSTEM FINAL VALIDATION fect. DATE d License Number Lic. Class. O V FI � Contractor Date O I am exempt under Sec. W B.BP.C. for this reason a' Plan check fee ► 2E Date: PLUMBING PERMIT ISSUING FEE$ O Signature _ TOTAL FEE SINGLE FAMILY wu° � dr►1AL�I HOME OWNEWBUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name c Law for the following reason-(Section 7031.5, Business and -CA 5 10 Professions Code): Address 'I, as'owner of the property,'will do the work and the City (QE_ G Tel. No. �167� `-�- -(3I. structure is not intended or offered for sale(Section 7044, �;�� ;it;k� Business and Professions Code). - CONSTRUCTION LENDING AGENCY =7 if ` 5 I hereby affirm that there is a construction lending agency for Uf -'u+ •.-i,l ] - 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 Sta ws regulating Plumbing, and hereby aufho ' e . pre. nfativ s of this County to enter upon the ab a-men i ed rop ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign Lure of Permittee DO tb 5 WORKERS'COMPENSATION DECLARATION 7sase7A I hereby affirm that I have a certificate of,.consept'self ' an 417 APPLICATION IF O R PLUMBING PERMIT insure,.or a•certificate of.Workers'Compensation Insura ,or , �, n certified copy thereof(Sec.38 ) / 600,Lab.C . i l COUNTY OF LOS ANGELES BUILDING AND SAFETY' Policy No. ��Compan% Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) PDR 7 {_� ❑ Certified copy is filed w1 t )ounty buildin pg inspection NUMBER FIXTURE OR ITEM • FEE P!% tme, t. WATER CLOSET - Date pplicant r BATH TUB CERTIFICATE OF EXEM T N FROM WORKERS'COMPENSATIO NSURANCE SHOWER -LAVATORY(This: section need not be completed. if the work involved, by the permit is for one hundred dollars ($100) or less.) , SINK CIT TEL.N W, I certify that in the performance of the work for which this DISHWASHER ' .permit is issued, I shall.not employ any person in any manner', CONTRACTOR ftr so as to.become subject.to the Workers'Compensation Laws. , CLOTHES WASHER ADDRESS O Date Applicant SWIMMING.POOL RECEPTOR r V CITY r NOTICE TO APPLICANT: If,after making this Certificate of TEL.N d,� t s+�G�T. Exemption, you should become subject. to the Workers' " LAWN SPRINKLER SYSTEM STATELIC. N Compensation provisions of the Labor Code,you must forth- LICENSE'NO CLAS Z with comply with such provisions or. this permit shall be WATER HEATER -: deemed revoked. GAS SYSTEM OUTLETS DISTRIC'T``NfOl.� PRO ESSED BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER , V a ,I hereby affirm that I am licensed under provisions of Chapter 5 PERSYSTEM 9 (commencing with Section 70.00)of'Division 3 of the Busi- FINAL j ness and Professions Code,and my license is.in full force and DATE VALIDATION effect. � (�1 � II F I N At_ License Numberd +IJ��. -j—y Lie.Class`z-2 3 �I BY \�,� � Contractcar� Date , i 0' I am.exempt from the licensing requirements as I'am a ;l- Plan check fee 7 licensed architect .or a registered professional engineer7 1 PLUMBING.PE:RWIIT ISSUING FEE$ Q " acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE t1 .. . .Lie.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm 'that I am exempt from the Contractor's " Address 'License Law for the following reason (Section.7031.5, Busi- City Tel.No, ness and Professions Code): 5 21.9 A I, as owner-of the property, am exclusively contracting # 0 0 0 0 0 with licensed contractors to construct the project (Section 7044,Business and Professions Code). 2 - CONSTRUCTION LENDING AGENCY I hereby affirm that; there is a construction lending agency o o,0 1 65010 for the performance of the work for which this permit is issued(Sec.•3097,Civ.C.). ,. - 0727'782 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 SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances -and State laws regulating Plumbing, and hereby authorize c presentatives of this County to enter upon the Netme ti ed pr p ty for inspection purposes.. i ature of rttee Date L