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Home My Public Portal About5319 PERSIMMON AVE_Plumbing__ L _ RKER1 rOhaveMPENSATION DECLARATION APPLICATION.-FOR PLUMBING.PERMIT- " it h Plfln' t`liat 1 have a certificate of consent to self 76A667A i' ��.,,,,,, a aertificate of Workers'Compensation Insurance, CE 817 REV. 10/81 �.-,.. _ ._ .... or d certified copy thereof(Sec. 3800, Lab..C.). COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.— o. Company Pol Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR'TYPE)'• -- 'BUILDING ❑ Certified copy is filed with the county building-inspec- ADDRESS 07 M10 tion department. NUMBER FIXTURE OR ITEM @ FEE Date Appl igant. WATER CLOSET NEAREST IF BATH TUB CROSS ST. � AArA-_ _ T teG� CERTIFICATE OF EXEMPTION FROM WORKERS' e_ , COMPENSATION INSURANCE OWNER (This section need not be completed if the work involved by SHOWER - C +4 S /� the permit is for one hundred'dollors($100)or less.) LAVATORY ADDRESS eh� CSS/d!'I M a� I'certify that in the performance of the work for which this permit is issued, I shall not employ 'ny person in any manner SINK CITY ' I /r, TEL.N !�/2 so as to become subject to t r ers'Comp sation Laws.. DISHWASHER L� CONTRACTOR ��_ /._�(,-� Date pplica CLOTHES WASHER NOTICE TO APPLICANT: If, after Makin this Certificate of _ ADDRESS Exemption, •you should become subject to .the Workers' SWIMMING POOL RECEPTOR s. , CITY TEL.NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM ' with,comply with such provisions or this permit shall be STATE, LIC. deemed revoked. WATER HEATERLICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION / ` DISTRICT NO. OCESSED BY GAS SYSTEM OUTLETS /)r I hereby affirm that I am licensed under provisions of Chapter 9 (/ (commencing,with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions.Code,and my license is in full force and effect. 5 PER SYSTEM. FINAL VALIDA ON License Number Lic. Class DAT r- FI L Contractor Date ❑ _ -� C I am exempt.under Sec. F B.&P.C..for this reason u Plan check fee n Date: PLUMBING PERMIT ISSUING FEE$ ,' -2639.7A ? 'SignatureD TOTAL FEE PC O �(� # 0 0 0'0 0 5 -17 Plan check,applicant b 8.8 SINGLE FAMILYER c� HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address 1,2 6=8 7 Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. 1, 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 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 ze repr % tattves of this County to enter upon the ab v .me't pro erty for inspection purposes: SEE REVERSE FOR EXPLANATORY LANGUAGE —.X6y Signature f Permittee Date O7 d ioRKERS'\COMPENSATION.DECL-ARATION APPLICATION FOR PLUMBING(PERMIT I�ff4m that I have a certificate of consent to self 76A667A .In n rg_o a Certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) I or av erttfied dopy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. BUILDING n ❑ FOR.APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS f E0�1SIII��/JO Certified copy is filed with the county building inspec- tion department. NUMBER FIXTURE OR ITEM @ FEE LocalaTY E L� C`►'/7" , -Date .. Appli4ant WATER CLOSETNEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.Ct /VP-11r0 COMPENSATION INSURANCE OWNER -;r (This section need not be.completed if the work involved by SHOWER E � E/LG[.��} (J G the ermit.is for one hundred dollars $100 or less. MAIL P ( ) ) LAVATORY ADDRESS 1 certify that in the performance of the work for which is permit is issued,1 shall not employ any person to any ma er SINK CITY LE .. TEL.NOPiBtf4J(1:Z so as to become subject to the W s'Comp ation ws. DISHWASHER CONTRACTOR D 01 G Date r pplic CLOTHES WASHER' ADDRESS NOTICE tO APPLICANT: If, ter making .this erttftcate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL.NO. .Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with complywith such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT f�p,,,r ESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS v U)u( 1 (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL �� VALIDATI N DATE ✓ n License Number Lic. Class FIN C. Contractor Date B ❑ _ ` C I am exempt under Sec. F B.BP,C. for this reason Plan Check fee Q Date. ui PLUMBING PERMIT ISSUING FEE$ 2 ,Signature TOTAL FEE Plan check,applicant SINGLE FAMILY � 4 HOME OWNER-BUILDER DECLARATION Nome o o;1 (�5 1 hereby affirm that I ani exempt from the Contractor's License 9 Address Law for the following.reason (Section 7031.5, Business and o 0 0 (a 5 Professions Code): City Tel. No. o �,'2 7 I, as owner of the property, will do the work and the I 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 i the performance of the work for which this permit is issued .(Sec. 3097, Civ. C.). Lender's Name I '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 author'ze. representatives f this County to enter upon the ab a eritione rope for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .� j P1.1 Signature o Perm(ttee Date