HomeMy Public PortalAbout9919 OLIVE ST_Plumbing__ WOIlfirm 't COMPENSATION DECLARATION of ATION Cc 61 ( 1 APPLICATION FOR PLUMBING PERMIT
I hereby a firm •th�4 I have a' certificate of consent to self cF: ear z-eo
insure,or a certificate of Workers'CompensatiorPinsurance,or
a certified copy thereof(Sec.3800,Lab.C.)
COUNTY OF LOS AN E LE :9B I L DSA Y
Policy No. Company
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) ILDING
❑ NUMBER FIXTURE OR ITEM • FEE �- ADDRESS
Certified copy.is filed with the county building inspection �
_
department. LOCALITWATER CLOSET
Date Applicant L NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
LAVATORY MAIL
(This section need not be completed if the work involved ADDRESS �7'T SD ✓%'
by the permit is for one hundred dollars ($100) or less.) }
SINK CITYS ' / TEL.NO. �� V
I certify that in the performance of the work for which this DISHWASHER CONTRACTOR / N
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER ADDRESS v O
Date ApplicantW
SWIMMING POOL RECEPTOR ,
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO.1
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. U3
Compensation provisions of the Labor Code, you must forth- WATER HEATER LICENSE NO. � SS
with comply with such provisions or this permit. shall be
eemed revoked. GAS SYSTEM °a OUTLETS —� DISTRICT
TNNO.
Q� OCES ED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
hereby affirm that I am licensed under provisions of Chapter IS PER SYSTEM
(commencing with Section 7000)of Division 3 of the Busi- DATEFINAtVALID ISN
ss and Professions Code, and my license is in full force and DATE
fect.
FINAL
ense Number Lic.Class BY
ntractor Date
I am exempt from the.licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE.$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
hereby affirm that I am exempt from the Contractor's Address -9 0 0 9.8 A
cense Law for the following reason (Section 7031.5, Busi- Tel.No.
ss and Professions Code): # 0 0 a o o 5
I, as owner of the property, am exclusively contracting 2 0 - 2500
with licensed contractors to construct the project
(Section 7044,Business and Professions Code).
25.00
CONSTRUCTION LENDING AGENCY 0 9_$ 1
hereby affirm that there is a construction lending agency
�r the performance of the work for which this permit is
sued(Sec.3097,Civ.C.).
ender',Name
.ender's Address
certify that I have read this application and state that the
►bove information is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
)rdinances and State laws regulating Plumbing, and hereby
authorize represe ayves �his Co y to enter upon the
bovelm itione rins 1 purposes.
I gnature.oV P rmittee Date
O-RKERS'�COMPENSATION DECLARATION 20-0026 DPW 4/90 APPLICATION FOR. PLUMBING PERMIT
I hereV1Iyfaffirm Rhat I have a certificate of consent to self in- 76A667A
sure;o a certificate of Workers'Compensation Insurance,or a
certified copy thereof(Sec. 3800, Lab. C.)
'fl
Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS-
a'.
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building Inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY ^f
WATER CLOSET(TOILET) �Q
Ddte Applicant � NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST.
COMPENSATION INSURANCE ER OWNER
SHOW
(This section need not be completed If the work involved by MAIL
the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CI / TEL. NO.CPS-S-.Xd
as to b ome subjectpto a Workers'C p nsati La DISHWASHER
/ ! CONTRALTO r--
Date L �licanT CLOTHES WASHER
ADDRESS 9 ��_
NOTI TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY „� �1 TEL. NO. g- Q
sation provisions of the Labe:Coder,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE _ LIC.
ed. WATER HEATER LICENSE NO. - CLASS
LICENSED CONTRACTORS DECLARATIONDISTRICT Nb. PROCESSEb BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS - �y
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER .ia
' �
and Professions Code, and my license is in full force and ef- 5PER SYSTEM FINALVALIDATION
fect. H6SE BIB DATE o' I �' r
License Number Lic. Class �� a
FINAL ACCT o a V
Contractor Date BY
I am exempt under Sec. 33031 ITEMS
333vyO0
B.&P.C. for this reason W
Plan check fee TOTAL 333�20
IL
Date: PLUMBING PERMIT ISSUING FEE$ Z
ca
Signature CHECK 333=20
TOTAL FEE 3
SINGLE FAMILY � CHANGE 00
HOME OWNER-BUILDER DECLARATION Plan check pli ant
I hereby affirm that I am exempt from the Contractor's License Name 0000_t7001 6/11l
Law for the following reason (Section 7031.5, Business and
96
Profess ns Code): Address a W-d- 68'23 1 AM 48
y, e J
�s owner of the property, will do the work and the Cit1j ��i9.s= Tel. No. -_&
JA—
structure isnot intended or offered for sale(Section 7044,
Business and Professions Code). Pilo,
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
outh ize re esenta. es of this County to enter upon the
ab - ned o erty for. Inspectio rposes.
�� / SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of P Ae Date r �/