Loading...
HomeMy Public PortalAbout5809-5819 ROSEMEAD BLVD_Plumbing__ WORKER'S COMPENSATION DECLARATION gp8B7DPW 9/89 'APPLICATION FOR PLUMBING PERMIT I heseWaffir;h'that 1 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.hWgpanO77,g!/ y� COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. [1=06m �l�o Certified copy is hereby furnished. _ , BUILDING +Q • '`' o FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS gv l I �OSe1N��l D B ❑ Certified copy is filed with the county b Idin Ins Won department. - NUMBER FIXTURE OR ITEM @ FEE ' LOCALITY �� em l �. ly Data Applican WATER CLOSET `�+ , IDI NEAREST CROSS ST. S v►�1,S CERTIFICATE OF EXEMP ROM KERS' BATH TUB ASSESSOR COMPENSATION INSURANCE MAP BOOK , PAGE PARCEL (This section need not be completed If the work Involved by the SHOWER /J� permit Is for one.hundred dollars($100)or less.) LAVATORY C &p OWNER C � I certify that in the performance of the work for which this permit �� is Issued, I shall not employ any person in any manner so as to e' SINK 4'' ;; } ', t, ADDRESS p24O become subject to the Workers'Compensation Laws. DISWASHER CITY EL.NO. Date Applicant CLOTHES WASHER CONTRACTWf NOTICE'TO APPLICANT;. If, after making this Certificate of le umD CL Exemption,.you should become subject to the Workers'Compensation i SWIMMING POOL RECEPTOR ADDRESS r provisions of the Labor Code,you must.forthwith comply with such ' j {� Yloop provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY 92/p,TEL.NO. 7Je�2�g_ a I hereby affirm that I am licensed under provisions of Chapter 9WATER HEATER (commencing with Section 7000)of Division 3 of the Business and 6 GAS SYSTEM OUTLETS ' g Q LICENSE STATE LIC. SZS �4 CLASS Professions Code,and my license is in full force and effect.. f DISTRICT NO. Q OUTLETS OVER PROCESSED BYp � V�// 5 PER SYSTEM License Number �2 Lic..Class e ! V FINAL VALIDATION W ', n fQt, , , DATE �Z��Q �► d• Contractor�f la cylrBNl Data •$-/5 R2. K O.a7 FINAL Z 0 I am exempt under Sec. BY B.&P.C.for this ren /e� + D. .5'15�9 , Signatu PLUMBING PERMIT ISSUING FEE$ aZ TOTAL FEE &0 ' Plan check applicant - SINGLE FAMILY � HOME OWNER-BUILDER DECLARATION Name P a I hereby affirm that I am exempt from the Contractor's License Law ' AC-ACI °s for the following reason(Section 7031.5, Business and Professions Address if Code): ` City Tel.No. ❑ I,as owner of the property,will do the work and the structure •-� is not Intended or offered for sale(Section 7044, Business TOT E f k 41 / m 4t7AU and Professions Code). , CL r-r l - CONSTRUCTION LENDING AGENCY �'I I hereby affirm that there is a construction lending agency for the �•`�ANGHE °'�• performance of the work for which this permit Is issued(Sec.3097, Civ.C.) y��ff 1 i�'L1LI'-C U Lender's Name ,�. , i Ail ,1 1017 Lender's Address I certify that I have read this application and state that the above , Information Is cc of. I a roe to comply with all County ordinances and ate law regal Ing Plumbing, and hereby authorize repress atives of County to enter upon the above-mentioned ty or Ins a on urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ataof PelmTUse Date ; 1 � woracoMPENSATION DECLARATION 200028.DPW 9/ee A887A APPLI�TIO.N FOR PLUMBING PERMIT 75 I hereby affirm th lave 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. (ge, ompany 0Qg}I NAIMI l cd 1p& COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. , 0 Certified copy is hereby furnished. ADDRESS © 1 ,1�I FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy Is filed with the county building inspection department. NUMBER FIXTURE OR ITEM @ FEE 1 4 LOCALITY 1 !�L_._ Date y'�2Applicant WATER CLOSET NEAREST rr�i 1 U 'V CERTIFICATE OF EXEMPTION FR M W RKERS' BATH TUB CROSS ST. ASSESSOR COMPENSATION INSURANCE (This section need not be completed If the work involved by the SHOWER MAP BOOK PAGE PARCEL permit Is for one hundred dollars($100)or less.) LAVATORY OWNER L� I.certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so.as to SINK MAIL !h �� co become subject.to the Workers'Compensation Laws. ADDRESS V � DISWASHER CITY LE) TEL.'N : M IN 6 Date Applicant CLOTHES.WASHER CONTRACTORq NOTICE TO.APPLICANT: If, after making this Certificate of wet SIos DeCI&LvW Exemption,you should become subject to.the Workers'Compensation SWIMMING POOL RECEPTOR G SYI'1 F3)N 6 i IWG:. provisions of the Labor Code,you must forthwith comply with such ADDRESS provisions or this permit shall be•,deemed.revoked.. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION - CITY Lo is TEL.NO. C w- 3 I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER G ®. (commencing with Section 7000)of Division 3 of,the Business and GAS SYSTEM OUTLETSAL CENSE NO. �f�i� CLCIISS C — Professions Code,and my license is in full force and effect. OUTLETS OVER DISTRICT NO. PROCESSED BY ! 5 PER SYSTEM d License Number'} Lid.ClassFINAL DATE X30 „a y VALIDATION nW. Contractof -App+ I INC• 'Date � W ❑ I am exempt under Sec, O FINAL Y AL10 ` ? B.&P.C:for this reason Date Plan check fee 2 re PLUMBING PERMIT ISSUING FEE$ Sig TOTAL FEE El _711TPlan check applicant_Qj, E FAMILY w ter r�M1'" i �, , �`f L SING HOME OWNER-BUILDER DECLARATION Name yr,' }o ( ,� I���Q r• s - I hereby affirm that I am exempt from the Contractor's License Law ACC °'F for the following reason(Section 7031.5, Business and Professions Address163.00 Code): 330-1 El 1, 80TV I,as owner of the property,will do the work and the structure i ITEM EM is not intended or and Professions Code)red for sale(Section 7044, Business r- TO7 AL 163 o 00 CONSTRUCTION LENDING AGENCY jou! " /�'//ry , CHECK - 163.010 I hereby affirm that there is a construction lending agency for the V CHANGE .00 performance of the work for which this permit is issued(Sec.3097, Civ.C) " Lender's Name of CwfOlZ)A $/21024/9_ Lender's Address V-34 &P+k SS LII.• 65-11 1 AM 1d I 131J I certify that I have read this application and sta a 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-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE o