HomeMy Public PortalAbout5434 ROBINHOOD AVE_Plumbing__ !VIA ,
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WOR�8 "PIENSAMIN ffiflcaUDECLARATION MMWA DPW �°° APPLICATION FOR PLUMBING PERMIT
I hereby arm that I have ■ cortMcats o} consent to self Insure,
or a certlfloate of Worker's Compensation Insurance, or a certifled
Seo.3800 Lab.0.) -
COUNTY OF L03/1AlCiF1.E8 DEPT.OF PUBLIC WORKS DPT. OF PUBLIC YYOFtl(8 DIV.
�ry 11
❑ CertMed copy Is hereby furnished- FOR APMCANT TO FILL W(PRINT OR TYPE) BUbDM
` AI>
flied with the buk&V
Nt�1aa Focnx3E OR rrFy � FEf Locum,
DateU WATER CLOBET NEAREST
� CFAT7FFCgTE OF D07dPTtON Ff10M WORIC$i8' BATH TUB eROw sr.
COMPENSATION INSURAt CE
(ThV section need not be oompMted ff the work tnvotwd by the SHOWER MAP BOOK PAGE PARCEL
penmtt is for one hundred doUan(3100)or fees.) OWNER
LAVATORY
I oerttfy that In the performsnoe of the work for wfllch this permit MAL
Is Issued, I shall rat employ any person In any manner so as to BINK ADORE88
become sub)ect to the Workers' Compensation Laws.
DISWASHER QTYTEL NO. +
D da ApPkeM CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR
Exemption,you should beoome"act W the Worker'Compensation SWr11IrNG POOL RECEPTOR ADOREes
a
provision of the Labor Code, you must forthwhh comply with euoh
provisionsr this permit shall be deemed revoked. LAWN 8PR1N9Efl 8YB®i Al
r LlCF7JSED CONTRACTORS DECLARATION CTY TEL-NO.
I hereby affirm that I am Ilosnsed under provisions of Chapter 9 STATE
WATT
(commenoing with Section 7000) of Dbvlslon 3 of the Buslneas anfyo p68
Professions Code, d my floenae to in full foroe and ell ( OAB SYSTEM OtJ1l fB d
r6 PER SYSTEM
DISTRICT �L/O. PFIDGEBSED BY
Ucerm Number Llo E
F AL VALDAIION
ContrAotor
DA's Z
❑ I am exempt under Seo. BY
B.BP.C.for this reason -
oaa Plan ctfeck tee ,
PLUMBING PIERMf1 ISSUING FEE S Qp
❑ i � TOTAL FEF �'tJ
Plan otiecic eQpBcarrt
SINGLE FAMILY
HOME OWNER-BUIU:?M DECLARATION Name t{ T.T
I hereby affirm that I am exempt from the Contractor's License Law
for the following reaeon (8ectlon 7031.6, Business and Professions Address D7 2TJ.`ki
Code):
El City Tel. No. 1 ITEMS
I,w owner of the property,will do the Work and the structure
In not Intended or offered for sale (Section 7044, Business . TOTAL 20 . 51D
and Profeestons Code). , CI-E�KLU.�43
CONSTRUCTION FENDING AGENCY 4411
I hereby affirm that then In a construction lending agency for the AI
performance of the work for which this perrnh Is Issued (Seo. 3097,
Ctv. C.)
Lbndaes Name 000M 11 9/13/91
?019 1 AM 9:7.
Lenders Address
I certify that I have read this applloatlon and state that the above
Information Is oornct I agree to oomply with all County ordinances ,
and State laws regulating Plumbing, and hereby authorize
Fspresentattves of this County to enter upon fhe above-menNonpd
property for Ina p SFE REVERSE FOR EXPLANATORY LANQUA13E
1
WOWRS'COMPE -SATION DECLARATION • • - APPLICATION FOR PLUMBING PERMIT
1 hereby affirm that I have a certificate of consent to self 7ZA667A
` Insure, or a certlficote of WorkerC
s' ompensatlosk In�suran£e, (0=817(REV. 10/V)
or cb certified copy thereof (Sec.3800, Lab. C.) COUNtY CIF LOS ANGELES / �' BUILDING AND SAFM .
+ Policy No.—CoMpany
❑ Certlfied copy Is hereby fumished, FOR APPUC 1Z TO RLL IN(PRINT COR 11 PE) BUILDING
❑ Csrtlftsid copy Is filed with the,County-building Inspec-
tion department. NUMBEIR RXTUREOR96A Q
. LOG41fTY
Date Appllgan► WATER CLOSET
CERTIFICATE OF EXEMPTION H2OM WORKERS' BATH TUB CR=ST W v
MMPENSATION INSURANCEf
(This*oc•FFan no"hot b*vgnlpletad PF tfrs work hndf d by � SJ K�W� ��"
the pertntt is for ons 1huHdred dollars (;100)of Isss.J LAVA,TOkY
I certify thaf In the,performance-of the work for welch this
permit is Issued, I"sball not employ any persoh In any manner SINK CITY �� /� �'� tEL NO..4/
toV
to as tq become sublect to the Workers Compensation Laws.,
DISHWASHER CONTRACTOR
t�mption,
P( plicant CLOTHF$WASHtR ADoPESS
TlC TO APPLICANT: If, after .making this Certlflcgta- of PQOI ��you should become subject to the Workers'
Compensatlotl provisions of the Labor Code, you mLr9t forth CITY TEL MO
with comply with such- provisions or this permit shall be LAWN SPRItUQE125YSTEM
STATE LIC
deemed revoked. WATER HEAD a CLASS
LICENSED-CONWRACTORS DECLARATIQN p
J hereby affirm thaf 1 ant Iltehsed unciw prbytilohs of Chapter'9 W SYSTW OUTLETS ' BY
(tomrrlencing with Section 7000) of Division 3 of the Buslness OUTLEfS OVER
and professions Code,'arx3 my license Is In full force and effect. 5 PER SYSTEMFINAL V_ ALIDATFQN
DATE License Number I Ic. Class , � U
FI
Confrottor Date BY O
❑ I om exempt udder Sec.
en
8.8P.C_ for this reason Plan chick fee'
Date:
$iflrwtu[e AL PLUMBING PSRMIT ISSUING FTE$' �� .1 2 6 9. 6 A —
TOTFEE # 0 0 0 0 0
SINGI-F FAMILY
Plan check applicant Q 0 o G Q 5 Q
- i
HOME OWNER-BUILDER DECLARATION Name fTi.Q rJ O
I-hereby affirrii that I am exemptfrom the Coniracior s License I
5.
Law for the following reason (Section 7031.5, Business and Add
fess 07. 13-8'4
Professions Code): City Tel. No. '
❑ I, as owner of the property, w1H do the work and the
itructore Is not Intended or offered for sale (Section ,
7944„Business and.Professions Codd). `
CONSTRt1C7I0N LENDING AGENCY
1 hereby affirm that there Is a construction lending ager"for
the performance-of the work for which this permit Is LnUed
(Sec. 3047, Civ. C.}
Lender'Y Nome' >t
Lender's Adr'ess
I certify that 1 have read this app0catlon and state that the ►
above Inforn-Keloh is correct. I agree tq comply with all County
orclincinces and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property for lhspe0lon purposes.
TEE REVERSE FOR.EXRLANATQRY I.ANQdJAGE
-7t ,
Signature of Permittee Date