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Home My Public Portal About9508 PENTLAND ST_Plumbing__ WORKERS'COI have aTIONDECLARATION l CE APPLICATION FOR PLUMBING PERMIT P hereby affirm that I have a certificate of consent to self ce rn (z-.o) ' insure, or a certificate of Workers'Compensation Inaurapce or - , a certified copy thereof(Sec 3800,Lab C') " COUNTY OF LOS ANGELES /f e- BUILDING AND SAFETY � Policy No Company „ Certified copy 6 hereby furnished i FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING q�OW n ADDRESS -/ I(n� y' Certified copy is filed with the county budding inspection NUMBER. ` FIXTURE OR ITEM '• FEE _ department WATER CLOSET LOCALITY Date Applicant ' NEAREST ' BATH TUB CROSS ST Qitr e CERTIFICATE OF EXEMPTION FROM WORKERS' t COMPENSATION INSURANCE SHOWER ,3 OWNER ,. )_ (This seaLAVATORY MAIL son need not be completed ll the work involved. ADDRESS / } by the permit is for one hundred dollars ($100)oess r l ) i SINK CITY t TEL NO _53f O I certify that in the performance of the work for which this - - U permit is issued, I shall not employ an DISHWASHER CONTRACTOR p p y y person m any manner •� ' so as to b come°subject to the Workers )ompen�on ws CLOTHES WASHER ADDRESS L,� ' Date APPhcant (.�[j�f U SWIMMING POOL RECEPTOR NOTICE TO APPLICANT If after rriakmg this Leru tate of CITY TEL NO W Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM Compensation provisions of the Labor Code you must forth STATE , LIC N with comply with such provisions or this permit shall,be WATER HEATER LICENSE NO CLASS Z deemed revoked GAS SYSTEM OUTLETS DISTRICT NOf�J PRO ESSED BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM + 9 (commencing with Section 7000) of Division 3 of the Buil FINAL VALIDATION ness and Professions Code and my license is in full force and DATEr �� effect FINAL License Number Ltc Class BY Contractor Date I am exempt from the licensing requirements as I am a Plan check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ seting m my professional capacity (Section 7051, Bus mess and Professions Code) TOTAL FEE �rp Lic or Reg No Date r Plan chuck applicant ' , f " HOME OWNER BUILDER DECLARATION Name , I hereby affirm that I am exempts from the Contractor's Address License Law for the following reason (Section 7031 5, Busi City Tel No - , 249 1 2 A ness and Professions Code) 1, as owner of the property, am exclusively contracting , " - # eJ with licensed contractors to construct the project (Section 7044 Business and Professions Code) Q•• 1 6 0 Q CONSTRUCTION LENDING AGENCY - ` t • 1 6 0 0 6 I hereby affirm that there is a construction lending agency ' for the performance of the work for which this permit is `0 4.23 —8 1 w issued (Sec 3097 Civ C) ' Lender's Name r , Lender's Address I certify that I have read this application and state that the r above information is correct 1 agree to comply with all County SEE REVERSE FOR EXPLANATORY L4NGUAGE ordinances and State laws regulating Plumbing and hereby authori>e representatives of this County to enter upon tae above mentioned property for inspection purposes ' Signature of Permittee Date Y WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT hereby, affirm that have a certificate of consent to self in- 76A667APW 4/67 sure,or a certificate of Workers'Compensation Insurance,ora CE 817(REV. 8/86) certified copy thereof (Sec. 3800, Lab. C.) fl Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS 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 OCA0TY Date Applicant WATER CLOSET(TOILET) NEAREST /^ CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB v CROSS ST. COMPENSATION INSURANCE SHOWER OWNER Ch'i (This section need not be completed if the work Involved by MAIL the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any manner so SINK d CITY TEL NO. as to become subject to the Worker ' ompeTSt Laws. DISHWASHER (� PP 1!M•/Aw� CONTRACTOR Dote L1421 -$g Applicant �4/ CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of Ex, ADDRESS emotion,you should become subject to the Workers'Co compSWIMMING POOL RECEPTOR - CITY TEL. NO. lotion 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 DISTRIcr NO.. PR ESSED 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 f and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VA ATION r tett. DATE Q. C License Number Lic. Class O FINAL G Contractor Date BY O H I am exempt under Sec. W 0. B.BP.C. for this reason ► �9 3 5 2 A = Plan check fee Date. PLUMBING PERMIT ISSUING FEE$ Signature # - - • - - 5 TOTAL FEE SINGLE FAMILY Plan check applicant I • '- 7 Q 50 HOME OWNER-BUILDER DECLARATION PP I hereby affirm that I am exempt from the Contractor's License Name `•,i - - 070505 Law for the following reason (Section 7031.5, Business and - Professions Code): Address U/1,. as owner of the property, will do the work and the City rP� GLS Tel. No. ' (p^/ 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 , ordiga es and State laws regulating Plumbing, and hereby Guth iz repres ta 'v s of this County to enter upon the ;.X entione pr er inspection pur ses. / SEE REVERSE FOR EXPLANATORY LANGUAGE Si ure of Permittee 0 DGte L