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Home My Public Portal About5760 PRIMROSE AVE_Plumbing__ r MPENSATION DECLARATION + 3. WORKC+�V C ' haWc+ s .certif'Cate of APPLICATION FOR PLUMBING PERMIT I hereb `officm ,spf Compensation to self 76A887A (} f Workers' Insure,oar a cerfif to '`(SeC. 3800, b C�1On Insurance, CE 817(REV.8/88) or a cerfifAbd copy therec-k_ Qf% __% �v� ) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. CompaK__... Certified copy is hereby furnished. "" ', BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) Certified copy is filed with the county buiI ir'ia.KIS, ,• w ADDRESS tion department. NUMBER FIXTURE OR ITEM FEE LOCALITY WATER CLOSET Date Appligont NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' I BATH TUB CROSS ST. COMPENSATION INSURANCE (This section need not be completed If the work involved by SHOWER s MAIL the permit is for one hundred dollars($100)or less.) LAVATORY �' _ ADDRESS I certify that in the performance of the work for which this permits issued,I shall not employ any person in any manner SINK CITYiK TEL.NO. C-6:]/6 so as to become subject to the Workers'Comp e tion Laws. DISHWASHER CONTRACTOR S L 2g Datey Appli n i CLOTHES WASHER 06 ADDRESS NOTICE TO APPLICANT: If er m ung this Certificate of Exemption, you should come subject to the War .' SWIMMING POOL RECEPTOR CITY TEL.NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall. be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ` (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL` ©� VA ATION DATE Q License Number Lic. Class FI Contractor Date ❑ I am exempt under Sec. 916 fA B.BP.C. for this reason Plan check fee SignaturDate: PLUMBING PERMIT ISSUING FEE$ e S TOTAL FEE qaJ Jr Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name A 7 0.1.5 A. I hereby affirm that I am exempt from the Contractor's License Address o 0 0 0 0 Law for.the following reason (Section 7031.5, Business and # 5 Profe ns Code): City Tel. No. ( o - 2250 I, as owner of the property,will do the work and the. structure is not intended or offered for sale (Section o 0 0 22505 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 051 Z $7 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.y. 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 lows regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-m tioned perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE gn tur Permittee Date W -1 WORKERS'c6wilNSATION DECLARATION, , ' APPLICATION FOR PLUMBING PERMIT 'I hereby affirm that I have tis certificate of consent to self 20-0026 DPW 6/87 ;.insure, or a certificate of Workers'Compensation Insurance, 7GA667A or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES. DEPT.OF PUBLIC WORKS Policy No. Company ❑ `'.Certified copy is hereby furnished. BUILDING r^ ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) � ADDRESS .� Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM ® FEE tion department. LOCALITY Date Applt4ant WATER CLOSET NEAREST � I! CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST. fS COMPENSATION INSURANCE SHOWER d OWNER y (This section need not be completed If the work Involved by 1:990 #, MAIL the permit is for one hundred dollars(:100)or less.) LAVATORY ADDRESS99 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 TEL. NO. g— .2 so as to become subject to the Worker ompensatio S. DISHWASHER CONTRACTOR Date pplica CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certifi a SWIMMING POOL RECEPTOR Exemption, you should become subject to the or ers' CITY TEL4 . 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. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NQ. OCE ED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (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 FINALVALIDATION Q DATE License Number Lic. Class �� FINAL Contractor Date BY C ❑ I am exempt under Sec. W B.BP.C. for this reason ® C' Plan check fee Cr Signature Date: PLUMBING PERMIT ISSUING FEE$ In J.10- ! - TOTAL FEE g J Q Plan check applicant SINGLE FAMILY S HOME OWNER-BUILDER DECLARATION Name pf��r•�0v� I hereby affirm that I am exempt from the Contractor's License gddress Law for the following reason (Section 7031.5, Business and 3307 Profes ' ns Code): City Tel. No. 1 1 LJ I, as owner of the property, will do the work and the TENS structure is not intended or offered for sale (Section ® TOTAL 3 c 50 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CHECK28°50 1 hereby affirm that there is a construction lending agency for CHAW 0( the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). ( Lender's Name 0000-MOI 8/16/89 Lender's Address 51151 1 AN 9027 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 outhorize're resentatives of this County to enter upon the above- oned property f inspectio/pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE vx "Signature of Permi ee ate