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HomeMy Public PortalAbout9312 OLIVE ST_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 20-0026 DPW 4/90 `I herebyy affiSm that I have a certificate of consent to self in- 76A667A , sure,ora certificate of Workers'�Compensation Insurance,ora certified cop;7 �� e�4�3�800, Lab. _ COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. mpany Certified copy is hereby furnished. 9 %'T G�V� / FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING f a' Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM ADDRESS , IIJJ department. @ FEE _ LOCALITY Ddte Applicant WATER CLOSET(TOILET) 'I NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' T I/ BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER /�1��� (f�7 SHOWER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS .�( � I certify that in the performance of the work for which this per- SINK CITY mit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws.' ,, DISHWASHER CONTRACTOR Date. Applicant CLOTHES WASHER ADDRESS / �' NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL.RECEPTOR emption,you should become subject to the Workers'Compen- CITY �� /J� TEL.NO. sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS " ,4 ! /D9 � � ly with such provisions or this permit shall be deemed revok- STATELIC. ed. WATER HEATER LICENSE NOIV, / CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSEb BY I hereby affirm that I am licensed under•provisions of Chapter GAS SYSTEM OUTLETS -r :eq/9(commencing with Section 7000)of Division'3 of-the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL >.VALIDATION fete. /f n rJ 'Q/ HOSE BIB DATE �i'r +- v (,/(!i �l{G License Number Lic. Class a FINAL V ContractoBY a .❑ I am exempt under Sec. �� IRCCT.0 V B.BP.C. for this reason Plan check fee W Date: PLUMBING PERMIT ISSUING FEE$ Q , a4�e � ? Signature SINGLE FAMILY TOTAL FEE HOME OWNER-BUILDER DECLARATION Plan check applicant 1 ITEMS I hereby affirm that I am exempt from the Contractor's License Name TOTAL 49 o �� Law for the following reason (Section 7031.5, Business and Professions Code): Address CHECK 349.30 E] 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, CHANGE Business and Professions Code). .00 CONSTRUCTION LENDING AGENCY , 0000-0001 10/24/95 I hereby affirm that there is a construction lending agency for 2967 1 AM10�OQ the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). t Lender's Name Lender's Address I certify that I have read this application and state that the oil.above information is correct. I agree to comply with all County ordina d State laws regulating Plumbing, and hereby auth • e re resentatives of this County to-enter upon the a me t' n prop Fty for i pection rpos s.— / �L SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATIOND LARATION 20-0026 DPW 4/90 APPLICATION FOR PLUMBING PERMIT J hereby,'affirm•that I have a certifi to of consent to self in- 76A667A sure,or a certificate of Workers'C pensation Insure e,ora certified copy thereof(Sec. 3800 lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Co pany l:] ©!Certified copy is her y furnished. Certified co is fi d th a coun uildin FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING' py g inspecti ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Dtlte ZApplicant ' Jf,J WATER CLOSET(TOILET) / NEAREST CERTIF TE OF EXEMPT 6 WORK BATH TUB CROSS ST. COMPENSATI S . NCE SHOWER OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK CITY TEL.NO. mit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Co pensatio La DISHWASHER I • // CONTRACTOR Date �Z-1[� Applicant CLOTHES WASHER ADDRESS 3' )�s)�►� D� NOTICE TO APPLICANT: If, after makin24 s Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject tEYfhe Workers'Compen.- CITY 5 TEL.NO.Z*[l•2y$( sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this pertnit shall be deemed revok- STATE LIC. ed. WATER HEATER 'LICENSE NO. S(8 CLASS Li LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS.SYSTEM OUTLETS v 9(commencing with Section 7000)of Division 3 of-the Business OUTLETS OVER !/ C and Professions Code, and m license is in full force and ef- 5 PER SYSTEM FINAL fect. y HOSE BIB DATE _ VALIDATION �j / License Number [J , Lic. Class FINAL Contractor ....,-�I �lAPr2 Date IL S.;.107 FINAL • � BY I am exempt under Sec. l u B.BP.C. for this reason Plan check fee ► H Date: PLUMBING PERMIT ISSUING FEE$ I Signature TOTAL FEE I'' .SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant SITE mr} � , I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5,.Business and CHECK 59° 0 Professions Code): Address U7 I, as owner of the property, will do the work and the City Tel. No. CHANGE °(JO structure is not intended or offered for sale(Section 70.44, Business and Professions Code). :► CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for 0000-0001 3/12/96 the performance of the work for which this permit is issued 5277 PH �p�� (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the 1111110.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 abo a entio pr rt r inspection purposes. S—12.,rg6 SEE REVERSE FOR EXPLANATORY LANGUAGE natur 0�P rrnittee Date