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Home My Public Portal About5232 PAL MAL AVE_Plumbing__ �J WORKEr RS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT � 76A666 DPW 4/87 »,�Rbys aF trm that I have a certificate of consent to self in- 76A667A 'fl surW�`a 91rtifiWte of Workers'Compensation Insurance,or a CE 817(REV.8/86) certecf ropy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company kt Certified copy is hereby furnished. �., FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING C ❑ Certified copy is filed with the county building inspection ADDRESS v department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET(TOILET) / Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. -� COMPENSATION INSURANCE SHOWER OWNER G (This section need not be completed if the work involved by MAIL / the permit Is for one hundred dollars($100)or less.) LAVATORY __ADDRESS.._5 / I certify that in the performance of the work for which this per- SINK CITY L� TEL. NO.. mit is issued, I shall not employ any person in any manner so t as to become subject to the Worker ompensation Laws. DISHWASHER _ 7 CONTRACTOR h Date r Appli a CLOTHES WASHER , NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY TEL. NO. sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION ` DISTRICI NO- / PROXESSED Y I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS `N G 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINALVALI TION >_ fect. DATE O License Number Lic. Class 0 S. 06� FINAL IIZ Contractor Date BY O t— I am exempt under Sec. W B.&P.C. for this reason :2 8 0 Q 3 A U) Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ ® # 0 0 0 0 0 5 I Signature g TOTAL FEE ( ° ° 1 6650 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant 40 'o 0 o 166500' 1 hereby affirm that I am exempt from the Contractor's License NameGSG Law for the following reason (Section 7031.5, Business and o9.28-87 Professions Code): Address �� L I` I, as owner of the property, will do the work and the City ,� C� Tel. No 3 / structure is not intended or offered for sale(Section 7044, Business and Professions Code). 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 ordina ces and State laws regulating Plumbing, and hereby auth ize representatives of this Cou y to enter upon the entioned p pert fo inspe purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE acute of Permittee Date , • "'� `W1JRoE�S'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �tirr�• ffi ��thti�t`I have q'certificate of consent to self 76A667A ilvre . rtificate of Workers'Compensation Insurance, CE 817(REV. 10/81) �J 'oc a ce't�opy thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building Inspec- ADDRESS 5-2,37 tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY 7f- `L ' Date Applicant 2 WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. - COMPENSATION INSURANCE OWNER dSC MAIL of (This section need not be completed If the work Involved by SHOWER the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS S Z.3 Z I certify that in the performance of the work for which this +permit is issued,1 shall not employ any person in any manner SINK CITY TEL.NO. so as to become subject to the Wo ers'Compensation Law . DISHWASHER CONTRACTOR D .pylic t '10 ?4e CLOTHES WASHER' ADDRESS NOTICE'TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject.to the Workers' CITYTEL.NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. ,deemed revoked. WATER HEATER r LICENSE NO: _ CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. )PROCESSED BY I hereby off irm•that I am licensed under provisions of Chapter9. GAS SYSTEM OUTLETS f (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is In full force and effect. 5 PER SYSTEM FINAL VALIDATIO DATE —Z, 4 License Number Lic. Class CC FIN G Contractor Date BY -1h* C I am exempt under Sec. L B.BP.C.. for this reason Lt Plan check fee ► a Date: u PLUMBING PERMIT ISSUING FEE$ A � Z Signature TOTAL FEE 3: SINGLE FAMILY Plan check applicant ` HOME OWNER-BUILDER DECLARATION. Name dJ�i I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City T.I. No. I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY ;17 2 9.1 A I hereby affirm that there is a construction lending agency for # 0000.05 .the performance of the work foe which this permit is issued 1 -o'o 4 Q 5 0 (Sec. 3097,Civ. C.) : o 0 0 4 Q 5 0 50 Lender's Name 0 6 2 2 m 8 7 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 authorize representatives of this County to enter upon the ab e-mentioned property for' Pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Date ,