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Home My Public Portal About9622 OLIVE ST_Plumbing__ ty,j •4.. `WOIi ER'S COMPENSATION DFpCLARATION 776M A PW 9/89 APPLICATION FOR PLUMBING PERMIT 11 1 hereby affirm that I,have a certificate of consent to self Insure, o�a',pertificate of Worker's Compensation Insurance, or a certified cop;;t#�f•hof(pec.3800 Lab.C.) , COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. CoVol mpanv�lsf tau/V Laq Certified copy is hereby furnished. BUILDING Z��, c ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) 40/vV G e� • Certified copy is filed with the county building inspection ADDRESS dep rim nt. NUMBER FIXTURE OR REM @ FEE O p W41 A/1^ LOCALITY �� P1� Date pelican • WATER CLOSET NEAREST VA CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. Y�'J COMPENSATION INSURANCE BATH TUB •� ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE ® PARCEL!/ permit is for one hundred dollars($100)or less.) LAVATORY OWNEU G gZ r I certify that in the performance of the work for which this permit MAIL /1 is issued, I shall not employ any person in any manner so as to SINK ADDRESS �,��Q'�� become subject to the Workers'Compensation Laws. 57 DISWASHER CITY �/ C T 6_Z 6� Date Applicant CLOTHES-WASHER `i NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Ne 1 C C f 5 #r-7- Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS J Cb provisions of the Labor Code, you must forthwith comply with such rY/ d provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY b TE > WATER HEATER 0. I hereby affirm that I am licensed under provisions of Chapter 9 Q (commencing with Section 7000)of Division 3 of the Business and STATE GAS SYSTEM UTLETS ( OUTLETS OVER C,, Professions Code,and my license is in full force and effect. LICENSE NO. C DISTRICT NO. PRCLASS PROCESSED BY�/ ��/�•��/`q, 5 PER SYSTEM 41®p G.d�Lf —�s� C License Number 7`17 7�/� Lie.Class O C /� �p FINAL ?0��j VALIDATION B' Atfor""S VO J � DATE / J Contractor � Date U r_1 FINAL Z I am exempt under Sec. FBY I B.&P.C.fot this reason -Plan check fee 0 Da / Signatur r PLUMBING PERMIT ISSUING FEE$ OGS d ❑ -01 or TOTAL FEE SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law ACCT.lar for the following reason(Section 7031.5, Business and Professions Address , h'} cry.`0 Code): 43 a El 1, Tel.No. +-30 1 1TEMS I,as owner of,the property,will do the work and the structure is not intended or offered for sale(Section 7044, Business , TOTAL -, Q and Professions Code). 50 CONSTRUCTION LENDING AGENCY CHECK 43,513 1 hereby affirm that there is a construction lending agency for the CHANGE .011 performance of the work for which this permit is Issued(Sec. 3097, Civ.C.) Lender's Name 130113-13001 113/ 8/90 Lender's Address 31082 1 AM 9:41 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-mentioned property for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE y. WORKEJRS'COMPQ4SATION DECLARATION 6 DPW 4/87 APPLICATION FOR PLUMBING PERMIT 1�.I herdo; m affirthat I have a certificate76A66 of consent to self in- 76A667A 3'are,'or acertificate'of Workers'Compensation Insurance,or a CE 817(REV..8/86) ce$.(fieS,coppy tthereof(&Sec. 5800, Lab. C.) Policy JN �+' �pony Sr�",� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ❑ Certified copy is hereby furnished. ADDRESS �(e ZZ�r Vl✓�� FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING `j Certified copy is filed with the courity building'irispection NUMBER FIXTURE.OR ITEM IE�' department. @ FEE LOCALITY Date Applicant WATER CLOSET(TOILET) NEAREST �/► -p CERTIFICATE OF EXEMPTION FROM WORKERS' /��/, ^ /�,�+ � BATH TUB CROSS ST.7eAJPL0'� / �a® COMPENSATION INSURANCE SHOWER OWNER E, COV T"is G-7— (This section need not be completed if the work involved by MAIL -the permit is for one hundred dollars.($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK CITY7e 6 �' 'TEL. NO. mit is issued, I shall not employ any person in any manner so a as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR eW PO Date Applicant / CLOTHES WASHER `� p ADDRESS -2CJ,ITV�J S NOTICE TO APPLICANT: If, after making this Certificate'of Ex- SWI N�MING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY AftAOTEL. NO.2 sation pfovisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM C 3 ly with such provisions or this permit shall be deemed revok- STATE2 Z CLASS ed. WATER HEATER LICENSE NO. J LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ®� Lt� 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINALy,+3[/ VALIDATION >• fect. DATE % a. License Number-?q-a44 Z- Lic. Class O FINAL cc Contra ctorlt 9 NIS CWiST. Date BY O I am exempt under Sec. W IL B.BP.C. for this reasonpop. W Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ 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 OCT.` Professions Code): Address ? City Tel: El 1, 3307 7(I o 5;.1 I, as owner of the property, will do the work and the TT-•. structure is not intended or offered for sale(Section 7044, 1= ,: Business and Professions Code). TOTAL. 20 .50 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for (.�I'ECK 20.:±!i the performance of the work-for which this permit is issued CHANGE .011 (Sec. 3097, Civ. C.). Lenders Name Lender's Address 4825 1 AN pa 351 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 ab e-mentioned proper for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SignatureW Permittee Dche