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Home My Public Portal About9417 OLIVE ST_Plumbing__ �� 'f WORKERS'COMPENSATION DECLARATION APPLICATION. FOR PLUMBING PERMIT I Lreby affirm that I have a certificate of-consent,to self -20-0026 DPW 6/87 ipp'sure,,or a certificate of Worl)ers'Compensation Insurance, 76AS67A ' oha certified copy thereof(Sec: 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS LLLIII Policy`Nm Company ❑ Certified�copy.is hereby furnished. BUILDING Q ❑ FOR APPLICANT TO FILL IN(PRINT OR.TYPE) ADDRESS' L' �UL Certified copy is filed with the county building inspec- _ tion department. NUMBER FIXTUREOR'ITEM @ FEE LOCALITY /n� / WATER CLOSET Ol! NOG VL Date Appligant NEAREST 0 CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER II (This section need not be completed iF the work Involved by ! SHOWER 160 �L. O the ermlt'is For one:hundred dollars $100 or-loss.) MAIL I P ( ) ) 'LAVATORY ®� ADDRESS I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner SINK CITY (_ C; TEL.NO. y so as to become subject to the Workers'Compensation Laws. DISHWASHER -CONTRACTOR Date -61 Applicant � CLOTHES WASHER .ADDRESS NOTICE TO APPLICANT: If, after makindJthis Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers.' CITY TEL.NO., Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall .be STATE LIC. deemed revoked. WATER HEATER LICENSE'NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRIg Np., PROCESSED BY I hereby off irm•.that I am licensed-under provisions of Chapter 9 GAS SYSTEM OUTLETS c(J� vX (commencing with Section 7000)'of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINALl��f ALIDATIONPATE o' License Number Lic. Class V FINAL Contractor Date BY ❑ I am exempt under Sec. V B.BP.C.for this reason oZ _ Plan check fee � Date: PLUMBING PERMIT ISSUING FEE.$ ./0 Signatures ' TOTAL FEE 0 Plan check applicant SINGLE FAMILY S HOME OWNER-BUILDER DECLARATION Name ACCT.01 I hereby affirm that I m exempt from the Contractor's License' Address Law for the followingreason Section 7031.5, Business and �� u�0 Profes ions Code): City Tel. No. 1 ITEMS , as owner of the property, will do the work and the structure is not intended or offeiFed for sale (Section ® TOTAL 34.50 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CHECK. 34.50 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CHANGE .00 (Sec. 3097, Civ. C.). Lender's Name OG00�0001 �f' /$� Lender's Address% �' �i$ 1 AM 924 1 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-mentioneropert for inspection purposes. C? SEE REVERSE FOR EXPLANATORY LANGUAGE ignature Permittee Date IORKERB'COMPENSATION DECLARATION Tar 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT irq that I hpve a certificate of cogsent to self in- 7.6A667A a eerti,F'c?=�of Workers'Con;pensation Insurance,or a CE 817(REV.8/86) cL�oyereof(Sec,3800 Lab. C.) COUNTY OF LOS ANGELESDEPT. OF PUBLIC WORKS Ji-`i ' Polic No, Company �;ertified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING iU� ] Certified Copy is filed with the county building inspection ADDRESS i� qq department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant -3 WATER CLOSET(TOILET) 1 NEAREST ' CERTIFICATE OF EXEMPTION FROM WORKERS' �. BATH TUB CROSS ST: COMPENSATION INSURANCEf SHOWER / OWNERAVI �v (This section need not.be completed.if the work involved by v MAIL the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS qq 'Ve-1 sT I certify that in the performance of the work for which this per- SINKp� !!22 u mit is issued, I shall not employ any person in any manner so �— -"l 1'fru. CITY . TEL. NO. — 1 as to become subject to the Workers'Compensation Laws. DISHWASHER '� r 1 CONTRACTOR Date Ct Applicant GL' CLOTHES WASHER NOTICE TO APPLICANT: If, after making thiAZertificate of Ex' ADDRESS cus QL 4 em tion,yo should become sub'ect to the Workers'Co en- SWIMMING POOL RECEPTOR P Y I P CITY TEL. NO. sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this.permit shall be deemed revok- STATE LIC. ed. WATER-HEATER LICENSE NO. LICENSED CONTRACTORS DECLARATION DISTRICT NO. CESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER C (� and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL 9 VALIDATIO'- fect. DATE4'- O License Number Lic.Pass V FINAL Contractor Date BY O r � I am exempt under Sec. W � � d B.BP.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License .Name Law for the following reason (Section 7031.5, Business and 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; Business and Professions Code). ® 0 i5 5 7 A CONSTRUCTION LENDING AGENCY # 0 0 0 0 0 5 I hereby affirm that there is a construction lending agency for the performance.of the work for which this permit is issued ° 3 650 (Sec. 3097, Civ. C.). 13 6.5 0 Lender's Name ' 091388 Lender's Address I certify that I have read this gpplication 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 -mentioned' operty for.inspectiori purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE , Signature of Permittee Date ORKEi3S'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT a. r '7AA667 DPW 4/87 'by aff(rm that I'have a certificate of consent to sglf in-, ,.;7bA667A - �. or a cettif.icdta of Workers'C-4npernsation Insurance,ora CE 817,(RFV.8/86) C , died: py tereof(Sep. 3800, Lab. C.) Policy Company, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Gertified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING M Certified• i�copy'is filed with the county building inspection ADDRESS ` L, department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST: 1 COMPENSATION INSURANCE SHOWER' OWNER (This section need not be.completed if the work involved by MAIL the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS C v(2/ S I certify that in the performance of the work for which this per- mit is issued, 1 shall not employ any person in any manner so SINK CITY —lkMqk, C fTEL:NO, q as to become subject to the Workers'Compensation Laws: DISHWASHER I CONTRACTOR Date - • Applicant CLOTHES WASHER ADDRESS NOTICE TO.APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY TEL. NO. •sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM ly.with such provisions or this permit shall-be deemed revok- STATE LIC. .ed. WATER HEATER LICENSE NO. SS LICENSED CONTRACTORS DECLARATION: DISTRICT N R ESS D BY I hereby-affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETSf 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER i fed,Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL V. LIDATION a DATE 0 License Number Lic. Class FINAL Contractor Date BY 0 0 I am exempt under Sec. W B.&P.C. for this reason ycc Plan check fee pop. Date; PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION5 I hereby affirm that I am exempt from the Contractor's License Name j'� s Low for the following-reason (Section.,7031.5, Business and ACCT-'a Zitnicture oris Code): Address as owner of the property, will do the work and the y �� e�l� Cit Tel. No. 1I.�.EMJ is not intended or offered for-sale(Section 7044, Business and Professions.Code). , T0I AL 16.50 t CONSTRUCTION LENDING AGENCY � f e [t I,hereby affirm that.there.is a construction lending agency for the performance of the work for which this permit is issued CHANE - .00 (Sec. 3097, Civ, C.). Lender's Name 0000-0001 11/ 3/8? Lender's Address 6561 1 AM10:44 I.certify that I have read this.application and state that the above information is correct.I agree.to comply with all County d. ordinances and State laws-regulating Plumbing, and hereby. authorize representatives of this County to enter upon the above- entioned propert for inspection purposes. //� _e jj SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of rmittee Date //