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Home My Public Portal About4955 PERSIMMON AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION ., '� APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consdrit to ell 2090026 DPW"6/87 insure, or a ceRtificate of Workers'CompensatiorvInsuran4e, 76A667A .� i or a certifibd copy,thereof(Sec. 3800, lab. C.) COUNTY OF LOS ANGELES DEPT.OF PU.BLIMORKS u Policy No. Y Company Certified.copy Is hereby furnished. , • FOR APPLICANT TO FILL IN(PRINT OR TYPE) BqILDING ADDRESS � /germ - m Certified,copy is ❑ filed with te county building inspec- tion department.. NUMBER FIXTURE OR ITEM @ FEE LOCALITY 7—eDate Applicant WATER CLOSET NEAREST Ole ar� J CERTIFICATE OF EXEMPTION FROM WORKERS" BATHTUB CROSS ST. COMPENSATION INSURANCE ' SHOWEROWNER 1 . • .(This section need not be completed if the work involved by the permit Is for one hundred dollars.($100)or less.) ' LAVATORY MAEA IL % te'ae 'f' ADDRESS I certify that in the performance of the work for which this permit is Issued,I shall not employ any person In any manner SINK CITY ,e7� TEL.NO:JW2-?,#4 so as to become ubject to the Workers'Compensation Laws. DISHWASHER t t CONTRACTOR Owner _ ev— Date pplicant ' CLOTHES WASHER ADDRESS NQTId TOAPPLICANT: If, after making t Certificate of SWIMMING POOL RECEPTOR Exemption, you ,should -become'-subject to the Workers' CITY TEL.NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. MLASS LICENSED CONTRACTORS DECLARATION Ip. RICT NO y D BY I hereby affirm-that I am licensed under provisions of Chapter 9 GAS.SYSTEM OUTLETS c_y/; a ' (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM. DATE Jp ✓� GLI ATION C License Number tic. Class V FINAL Contractor Date BY ❑ 1 am exempt under Sec. C LIJ B.BP.C. for this reason Plan.Check fee ► CC Date. ' PLUMBING PERMIT ISSUING.FEE$ Signature TOTAL FEE AR loo SINGLE FAMILY Plan check applicant Jr^I! N k—!., 5 HOME OWNER-BUILDER DECLARATION Name ACCTOr I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address e-1 KE Z r 3307 43 00 Professions Code): City ( �f Tel. No. -Z 1 ITEMS I, as owner of the property, will do the work and the .... structure is not intended or offered for sale (Section TLA! 43®i1310 7044, Business and Professions Code). CHECK 43000 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for CHANGE o0G the performance of the work for which this permit is.issued (Sec. 3097, Civ. C.). Lender's Name 0000-0001 4/23/90 0257 1 AM101;211 Lender's Address 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 repre:ientatives of this County to enter upon the above-menti pro erty for inspection purposes. < � 23 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee D e fill' ;• ' :WQRKERS'COMPENSATION DECLARATION - APPLICATION FOR' PLUMBING PERMIT I he}eby, affirrh'that'I h'aJg a ceh41ggfe of consent to self in- 76DPW 4/87 6A667g sure,or a cgrtificote'bf Workdfs'Corrfpensatiool Insurante,or a. CE 817(REV.8/86) Certified copy thereof(Sec. 3800, Lab. C.) _ COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS 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 inspection ARESS• DD �`7 7v' ed'Sl�ij611 Dd�l Ue� department. NUMBER FIXTURE OR ITEMFEE LOCALITY f �L WATER CLOSET(TOILET) � 5b e111 / Date Applicant ✓ - NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' `.J BATH TUB �� CROSS ST. (VaI1,761 COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars'($100)or less.): % LAVATORY "y Sb ADDRESS 7,J� ,r51 U�'/ AM I certify that in the performance of the work for which this per- SINK / trait is issued, I shall not employ any person in any manner so CITY /��f�4 y TEL. NO,f��2� as to become subject to the Workers' ompensatio Laws.' DISHWASHER CONTRACTOR00 Date Applicant CLOTHES-WASHER ADDRESS NOTICE'T APPLICANT: If, after making this Certificate of Ex- emption,you should become subject to the Workers'Compen- CITY TEL. NO. sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. 'CLASS LICENSED CONTRACTORS DECLARATIONDISTRICT NO. SSED BY - 'I hereby affirm that I am licensed under provisions of airChapter r GAS SYSTEM 6'OUTLETS r ,9(commencing with Section 7000)of Division of the Business OUTLETS OVER � , and Profession's Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION fect. DATE f 4P License'Number Lic. Class (®j FINAL ContractoF Date BY O i'am"exempt under Sec. UJ B.&P.C. for this reason Plan check fee g Date: PLUMBING PERMIT ISSUING FEE$ Signature h TOTAL FEE V SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION pp icant 1 hereby affirm that I am exempt from the Contractor's License Name ACCT.V Law for the following reason (Section 7031.5, Business and Professions Code.): Address JV7�} rr J7 8Va00 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,: 1 ITEMS Business and Professions Code). ® TOTAL 88.00 CONSTRUCTION LENDING AGENCYCK Vo 00 (hereby affirm that there is a construction lending agency for the performance of the work'for which this permit is issued .011(Sec. 3097, Civ. C.). CHANGELerider's Name 0000_0001 1/ 2/9 0 Lender's Address i 7926 1 AM 9:35 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 Plumb'ing, and hereby authorize representatives of this County to enter upon• the Ob o entio Od rope rt for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date