HomeMy Public PortalAbout6017 PRIMROSE AVE_Plumbing__ �flemthER'SCOMPENSATIONDECLARATION S�BDPw9/89 APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self Insure,
or.a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C:)
Policy No. Company COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS ; . DEPT.OF•PUBLIC WORKS'DIV.
❑ CertifiI is hereby.furnished. A ✓
f FOR APPLICANT TO FILL IN(PRINT OR TYPE) DDRESS . O
❑ Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM i FEE
LOCALITY
Date Applicant WATER CLOSET NEAREST
J CERTIFICATE OF EXEMPTION FROM WORKERS' _ '!j _ CROSS ST. _
COMPENSATION INSURANCE ✓ BATH TUB ASSESSORg
(This section need not be completed if the work Involved by the SHOWER
OK PAGE FARCE
MAP BOS L Age?,
permit is for one hundred dollars($100)or less.) OWNER ti• ,
I certify that in the performance of the work for which this permit LAVATORY
Is issued, I shall. not employ any person In any manner so as to SINK ADDRESS
become subject to the Workers'Compensation Laws.
® DISWASHER CITY TEL.NO.
Date 7 Applicant dJP4 Aw CLOTHES WASHER CONTRACTOR T
NOTICE TO APPLICANT: 11, after making this Certifica of v b
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions-of the Labor Code,youlmust forthwith comply with such
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SQYSTEM
LICENSED CONTRACTORS DECLARATION ` CITY TEL.NO. +r Z d
4
I hereby affirm that I am licensed under provisions of Chapter 9 1 WATER HEATER
(commencing with Section 7000)of Division 3 of the,Business.and GAS SYSTEM OUTLETS CENSSTEE NO. CLASS
Professions.Code,and my license is In full force and effect. OUTLETS OVER DISTRICT NO. PROCESSED BY iY
— j 5 PER SYSTEM 0ZJ O
AH
License Number t( O ( Lic.Class�L 1
'^ FINAL •- 7 VALIDATION a
U DATE .` " d�J o �
Contractor d ate Z n 7 �.
l� FINAL +�30 (a o of 0 Z
p/LJ\ I am exam under Sec. BY
B.$P.C.for this I IfI ITEMS
1 Plan check fee , TOTAL 273. 6
i PLUMBING PERMIT ISSUING FEE$ CASH o t' .�o 0
Signatu TOTAL FEE
ElCHANGr_ -.00
Plan check-applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name fl:Ul� � 1 %�L�,�
I hereby affirm that I am exempt from the Contractor's License Law
for the following rekson(Section 7031..5, Business and Professions Address x'262 f AM10:33
Code): '
❑ I,as owner of the property,will do the work and the structure City Tel.No.
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 Stat la s gul ;d: hereby authorize
representa've of t o ne above-mentioned
proper r SEE REVERSE FOR EXPLANATORY LANGUAGE
�4an ure c PermitteeDate
WORKERS'COMPENSATION DECLARATION
6 DPW 4%90 6A66APPLICATION .FOR PLUMBING PERMIT
1 hereby, affirm that I have a certificate of consent to self in- 7
sure,or a certificate of Workers'Compensation Insurance,orn 6A667A ?
certified copy thereof(Sec. 3800, Lab. C.) I COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
.❑ Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO.FILL IN(PRINT OR TYPE) / d 1 7 6611 �/ °ti TL
Certified copy is filed with the county building inspection' NUMBER FIXTURE OR ITEM ADDRESS (7
department. @ FEE LOCALITY r
Ddte Applicant WATER CLOSET(TOILET). NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. �
COMPENSATION INSURANCE I SHOWER OWNER
(This section need not be completed If the work involved by MAIL
the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS a&v
I certify that in the performance of the work for which this per- `�
mit is issued, I shall not employ any person in any manner so SINK CITY a/1.4bA. �,gw TEL.NO.
as to become subject to the Workers'Compensation Laws. DISHWASHER
. ,�.L ,� �. 5,� CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS-
NOTIC..E TO APPLICANT: If, after making this Certificate.of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Com.pen- CITY TEL.NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS '�
ly with.such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO.. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER fj
and Professions Code, and my license is in full force and df- 5-PER SYSTEM FINAL VALIDATION
fect.. • HOSE BIB DATE
}
License Number I:ic. Class a
FINAL C
Contractor Date BY V
5 O
I am exempt under Sec. . V
e£
B.&P.C. for this reason Plan check fee - 3 122.55'
Date: PLUMBING.PERMIT ISSUING FEE$ ab iITEMS
Signature TOTAL FEE T �AL s�tc_e
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
CHECK
I hereby affirm that I am exempt from-the Contractor's License Name {i fih�IGE .00
Law for the following reason (Section 7031.5,-Business and
Professions Code): Address
I, as owner of the property, will do the work and the City.. Tel. No. 0Ql.)0_0001 6/2'2/95
structure is not intended or offered for sale(Section 7044,1
y`
Business and Professions Code). , 1004 1 AM 8°12
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 poll
ordinances and State laws regulating Plumbing, and he
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
6 . 2 B , I I- SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date