HomeMy Public PortalAbout5806-5808 PRIMROSE AVE_Plumbing__ WQRKA'.CQMPENSATiON DECLARATION APPLICATION FORPLUMBING PERMIT
"I�t��eyeb ffirmat I have a certificate of consent .to self
� ➢Sure, of q'certificate'of Wgrkeis Compensation Insurance, C 8177(REV. 10781) u
or,q ci4ified copy,ithereef(Sec. 3800,.Lab. C..) COUNTY OF LOS ANGELES BUILDING AND.SAFETY
Policy No. � " Company • -
Certified copy is;hereby furnished. a
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ,
Certified copy is filed with.the county building)nspec- ADDRESS. Q
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY t
WATER CLOSET1
Date Appligant NEAREST
BATH TUB: it o CROSS ST.i JA
CERTIFICATE OF EXEMPTION FROM WORKERS' V -
COMPENSATION INSURANCENER A _
'(This.section,need not be:completed If the work Involved by SHOWER 00 OW
the.oermif Is'for one hundred dollars,($100)or less.) LAVATORY ADDRESS O. �S..
.certify that In the performance of the work for whic is 1
.permit is issued,I shall•not employ any person in any .an er StNK 0:AL CITY �H TEL..NO.
so.as to become subject to.the Workersn CompeniscLtigfnLgfws. DISHWASHER
�} CONTRA.CrOR /
Date- Applicant CLOTHES WASHER ^
PP � 2 D
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Ekem tion, yo should become subject to the Workers' SWIMMING POOL RECEPTOR:
P Y I - CITY TEL.NO.
Compensation provisions of the Labor Code, you must forth- ', 'LAWN SPRINKLER SYSTEM
with comply with such .provisions or this permit shall be STATE LIC..
deemed revoked. WATER HEATER raq Ob LICENSE NO. QASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. OC,SED BY
GAS SYSTEM OUTLETS nn C
• I hereby affirm•thot I om..lteensed under provisions of Chapter 9 � o�.
(commencing with Section 7000)of Division 3 of the Business OUTLETS ER
and Professions!Code;and my I!cense-is in full force and effect. 5 PER SY5TEM FINAL
V f1DAT90N
DAT a
License Number Lic.•Class C
FIN. C'
Contractor Date BYIk
I am exempt under Sec.
C
B.$P..C. for this reasonI+
• . 'Plan check fee _ C
Date: v
i PLUMBING PERMIT ISSUING FEE$ ?
Signature
TOTAL FEE
11b(2 IS70
Plan check applicant
SINGLE FAMILY 4 8 S 8 A.
HOME OWNER-BUILDER DECLARATION Name
I hereby.affirm that I am exempt from the Contractor's License Address # 0'0-,0 0 0 5
Law for the following reason (Section 7031.5, Business and
Pr fe =ons Code): ' Pty Tel. No. o; r
Y ,I 1 .6,Q 5 0
I, as owner of-the property; will do the work and.the E
structure is not intended or offered for sale (Section ® :.o o l 6 Q 5 0 5
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY -o G 2,0 a 8 6
1 hereby affirm that there is'a construction lending agency for
the performance of the work for which this permit is issued
(Sec.:0097,'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'arid,State laws regulating Plumbing, and hereby
authorize representativ f this County to enter upon the
above ntioned. o ert for inspection purposes.
SEE REVEft$E.FOR EXPLANATORY LANGUAGE
4 ~120_00<0
Signature of Permittee Date
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
eia€firm. $hat'1„have,a ryertificate of consent to self 76A667A
1 instlie� or d c0rtificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
o%-d certifil;'d copy-thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. n Company
Certified copy is hereby furnished.
' FORBUILDING.APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS.
Certified copy is filed with the county building inspec-
tion department. NUMBER. FIXTURE OR ITEM FEE LOCALITY
Date Appligant LA WATER CLOSET NEAREST' -
/s CROSS ST.
BATH TUB �.
•CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE O OWNER
(This section need not be completed if the work involved by SHOWER '
the permit is for one hundred dollars($100)or less.) LAVATORY p2 ADDRESS 0. BX
I certify that In the performance of the work for which this
permit is issued,I shall not employ any person in.any nerSINK CITY TEL.NO. 3
so as to become subject to the Workers' mpensat ws. DISHWASHERP�
CONTRACTOR
Ar Date 602-0"� mki
Applicant' 'CLOTHES CLOT,HES WASHER; b
NOTICE TO APPLICANT: If, after ang this Certificate of v ADDRESS
Exemption, you'should become subject to. the Workers SWIMMING POOL RECEPTOR
CITY TEL.NO:
Compensationprovisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply. with such provisions or this permit shall be STATE C.
deemed revoked. WATER HEATERLICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. MS/SED Y
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM Is Al OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER (/Q
and Professions Code,and my license-is in full force and effect. 5 PER SYSTEM FINAL ,�47
VAL .I TION
DATE }
LL
License Number Lic. Class C
FIN U
Contractor Date BY a,
❑ C
'I am exempt under Sec. C~.7
B.&P.C. for this reason W
Plan check fee d
Date: CJuld
.. PLUMBING PERMIT ISSUING FEE$ J
Signature 9 4 8 5 7•A Z
TOTAL FEE
Plan check'applicant # o 0.0 0.0 5
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name I o l 6Q,50
I hereby affirm that I am exempt from the Contractor's License
Law .° a.l 6 Q 5 0 v
Law for the following reason (Section 7031.5, Business and
Prrnfe/ssi`ons Code): City Tel. No.rri06 2 0``$6
L_9ff I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section Poo7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending-agency forthe 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
authorize representatives of this County to enter upon the
above-snen}ioned�ertypection purposes.
®J }��`O� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date