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Home My Public Portal About5505 ROSEMEAD BLVD_Plumbing__ WORKER BCOMPENSATION DECLARATION to 75A4VA DPW 9/8D APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate o/consent to Belt Insure 7aAea7A or a carllficala of Worker a Compensation Insurance or a certified copy thereof(Sac 9800 Lab C) Poky N.09- Vs/ -09 "in �kf�t t COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV ❑ Carolled copy b hereby furnished FOR APPLICANT TO FILL W(PRINT OR TYPE)Cartilled copy A=S�8 Is filed with the countybu0dlrrp Inspection deparfmantNUMBER FIXTURE OR RLOCI-AMEN p FEE O O.h. 4 t 13.03-ApoItam—rM G.►dIA LT uAJ /L WATER CLOSET N6IREST cRoss Br _� WR. CERTIFICATE OF EXEMPT10N FROM VCORIffRB' BATH TUB COMPENSATION INSURANCE O (This section need not be completed H the work Involved by the SHOWER MAP ASSESSOR J 7 PAOEO 3-2 PARCEL O/_? permit to for one hundred dollan(11100)or less) 2 LAVATORY OWNER C O S I certify,that In the performance o1 the work for which this permit MAIL Q is Issued I $hall not employ any person In any manner so as to SINKAODRE98 / become subject to the Workers'Companoation Lave DISWASHER CRY DBI$ Appkeam CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT If alter making this Certificate of ` V Exemptan you should become subject to the Worker'Compansstldn SWIMMING POOL RECEPTOR ADDRESS provislors of the Labor Code you must forthwith comply with each &&- Provisions.r this permit shell be deemed revoked ' LAWN SPRINKLER SYSTEM p LICENSED CONTRACTORS DECLARATION WATER HEATER CRY W COV tNlta l I - a I hereby affirm that I am licensed under provisions of Chapter 0 STATE 11C r 8 (commencing with Section 7000)of DlAsion 9 of the Business err0 (lits SYSTEM OIRLETB UCEl76E NO CLASS Profeaskuls Code and my license Is In full force and affect / OUTLETS OVER DISTRICT NO p� PROCESSED BY cc Lkxrwa Number. �0 f-1 L, 3 l Uc Ctam 5 6 P ApGILL � 0 Donaao o`T a�) 4-13(J/3 DATE _Z _ VALIDATION a $.xT•2uc.Ttst.Date N ❑ I am exempt under Sec FINAL � ? e aP C for this reason sb B-o ACCT.i Dare Plan check fee SignaturePLUMBING PERMIT ISSUING FEE$ Poo. 3307 325.b15 ❑ TOTAL FEE G 1 ITEMS SINGLE FAMILY check epplieent TOTAL 325 . 65 HONE OWNER BUILDER DECLARATION Name CHECK M.65 1 hereby affirm that I em exempt from the Contractor•License Law •��w��uy�� for the following reason(Section 7091 6 Business and Professions Address 1.T1ftITl]G .00 Code) (qty Tel NO ❑ I d owner of the property will do the work end the Business 'non-n is not Intended or offered /or cele(Section lou Business , X00-0001 4/13/9 and Professions Code) 9191 1 Am 10:39 CONSTRUCTION LENDING AGENCY I hereby affirm that there Is a construction lending agency for the periormance of the work for which this permit is Issued(Sac 9097 Ov C) Lenders Name Leder a Address ` (kCAt?ISNTi 1 certify that I have read this application and state that the above 110.Information Is correct I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize repo senlalivm of his bun to nter upon the above mentioned prod ny for Inepec on urpoa a SEE REVERSE FOR EXPLANATORY LANGUAGE S(IQnature f Permittee ' Daid WORKER I have COMPENSATION DECLARATION DPW 9189 APPLICATION FOR PLUMBING PERMIT 1 hereby affirm that I have a certificate o1 consent to Gell Insure, or a Certificate of Worker a Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) K L Company, Gew%W 1 COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV ❑ COMW copy is hereby lunrishad AD 8�8 J FOR APPLICANT TO FILL IN(PRINT OR TYPE) ElCenlfbd coPY b coed with urs county building keepecuorl department NUMBER FD(TURE OR ITEM O FEE LOCALITY Dere APpfkantWATER CLOSET CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST BATH TUB COMPENSATION INSURANCE MMAAPP pp PARCELO/� (This section need not be completed It the work Involved by the SHOVER PAGE permit Is for ons hundred dollars($100)or Mp) UVATORY OWNER I conity that In the performance of the work for which this permit is Issued 1 shell not employ any person in any manner so as to Spix ADDRESS OD become subject to the WoWorkersCompensCompensationLaws ADDD WSWASHER TEL NO Date Appt, ofuff CLOTHES WASHER CO!lfRACTOfi NOTICE TO APPLICANT a alter making this Certificate of T.AL ExemlMbn you should became Yousubml t the With co Cly with such SWIMMING POOL RECEPTOR provisions of fed Labor Cada you must forthwith Comply with such ADDRESS provisions or this permit shall be deemed revoked LAWN SPRBIIQER SYSTEM LICENSED CONTRACTORS DECLARATION WATER HEATER CITY 1A.1 COJ I�h TEL NO 914-a7>7 a I hereby affirm that I em licensed under provisions of Chapter B IL (commencing with Section 7000)of Division 3 of the BusinessSTATE LIC 15 and OAS SYSTEM OUTLETS LICENSE NO -D 1 CLASS Professions,Code and my Scene is In full force and effect J L�.� OUTLETS OVER DISTRICT NO PROCESSED BY Q Lkarue Number Lf 11 �e 3 iii Lk pan 6 PER SYSTEM ` o� Y / Q FINAL U VMM ION DDATE •Z 3contractoW ❑ I am am ower Sec FINAL 3307 508.01A By B AP C for this Meacn 1 ITEMS Dale Plan Check fee 00 ► TOTAL 508 . 00 Signal" PLUMBING PERMIT ISSUING FEE$ DECK 5M.Ori ❑ TOTAL FEE UWE .00 SINGLE FAMILY Plan chock applicant HOME OWNER BUILDER DECLARATION Narita nnMnnn I hereby affirm that I em exempt from the Contractor a License Law 0000"0001 3/ 1/93 for the following Mason(Section 7031 S Busl"ss and Prolaeskna Address Coe) city Tai NO 0410 1 AM 9:53 I as owner of the property will do the work and the structure is not Intended or offered for cele (Section 7G44 Business and Professlons Code) ' 7 CONSTRUCTION LENDING AGENCY 1 hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is Issued (Sac 3097 CN C) ^.( Larder's Name 00tAnII1ALIM LM , )AAt IL Lender's Address_�M AIOeTPJ A- I certify,that I haw 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 representative of this County to anter upon the above mentioned pro rtY Ter Inap elbn,purpgeee SEE REVERSE FOR EXPLANATORY LANGUAGE U Slpneture Gf Permittee Dffie WORKER I haveCOMPENSATION of consent 7SA°Pl"°tier APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of COnsant to self Insure or a certificate of Worker a ComPenealion Insurance or a certified copy thereof(Sec 3800 Lab C) Policy No L&C ZAN? 1 Company CIM-0 A 811064-� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV ❑ Conrad copy u hereby furnished FOR APPLICANT TO RLL W(PRINT OR TYPE) BUILDING O deprrat b Bbd.0 the ceumy building kmpInspection, ADOREBB eParitretm Md NUMBER FUTURE OR fTEM O FEE LOCALITY Dela Applicant_ U&a•—— WATER CLOSET NEAREST ST CERTIFICATE OF EKEMPT ON FR WORD BATH TUB CROSS y COMPENSATION Id it th work MAP PAGE O:! PARCEID�3 ASSESSOR (Tab eeetbn need not G caaplNaO 11 the rorY bvolved by the S/NDW� *1&—e � Permit b for one hundred dollars(8100)or Is") LAVATORY OWNER O!J *1D 6N Z,O AU/ I cenily, that In the performance of the work for which this permit 1u111 , la issued I shell not employ any person In any manner so u to B1 ADDRESS D GAS become subject to the Workers Compensation Laws 40 DtSWABNER CT' *&j 94R/& TEL NO Del° AIk>tlavlt CLOTHES WASHER TCI+ 1 A U CO NS i RU r—T1 NOTICE TO APPLICANT If alter making this Certificate of Exemption you should become subject to the Workers Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code you must lonhwith comply with such ADDRESS S provisions or this permit shell be deemed revoked LAWN SPRINKLER SYSTEM UCENSED CONTRACTORS DECLARATION CRY aL TEL NO 9 �' I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE ND '� CLASS Proleeebns Cade and my license b In full force and onion S PER TS OVER DISTRICT SSED BY cccc 5 PER SYSTEM OYER Number `-�'7?�3� Lt. �,,, /' �� FINAL VALIDATION a Cant.h.,,AJ `o/Js% DMe o/y/ ._ to ❑ I am exempt under Sec BFI AL ? B aP C for this reeaen Date Plan check fee , Signature, PLUMBING PERMIT ISSUING FEES to 0 ❑ TOTAL FEE Plan check appDcant HOME OWNER BUILDER FAMILYPlan Name ACCT.0 I hereby storm that I am exempt from the Contractor•License Lew for the following reason(Section 7031 S Business and Processions Addrasa `:O.i 41.Z! Code) qty Tel No 1 ITII13 ❑ 1 "owner of the property will do the work and the structure Is not Intended or oflered for sale(Section 7044 Business TOTAL 41 . $5 and Professions Code) 010. CECK 41.°5 CONSTRUCTION LENDING AGENCY CHS I hereby affirm that there b a construction lending agency for the performance of the work for which this permit is issued(Sec 3097 CW C) I~a Name Co sm M L),y IT4 ?41.11& 0000—D001 g� 4�9' 1094 1 Am 8,24 LaMar s Address I certify that I have reed this application and Mete that the above ► Information Is correct I egr"to comply,with all County ordinances and Stale laws regulating Plumbing and hereby authorize representetivee of his Ccu y to enter upon the above mentioned pro rty roti Insp. no _ J3SEE REVERSE FOR EXPLANATORY LAIKiUALiE ^ P Slgnatu of Perrnittee