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Home My Public Portal About6011-6015 ROSEMEAD BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION I APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished.❑ BUILDING cc FOR 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 � �� C� pate Appliqant WATER CLOSET NEAREST j CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OVkNER (This section need not be completed if the work involved by MAIL SHOWER 22 ,(/ £� the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS %J / 73 `/ Io6lsG "q r= e-. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY r /` TEL. NO.2,yo-6151j— so G/51j-so as to become subject to the Workers'Compensat' n Laws. DISHWASHERJ f/ CONTRACTOR - c -�y /,,!' Cate � Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after Makin this Certificate of ADDRESS ?30 Exemption, you should become subj ct to the Workers SWIMMING POOL.RECEPTOR CITY ;r TEL.NO. LAWN SPRINKLER SYSTEM Compensation provisions of the Labor Code, you must forth- Jr/!�/P/ L �lrl�y.�y ' with comply with such provisions or this permit shall be STATE ^7 LIC. deemed revoked. WATER HEATER LICENSE NO. J 7 Gam% CLASS G LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS e• -� (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and m license is in full force and effect. I 5 PER SYSTEM Y I FINAL . VALIDATION i DATE �— O License Number yG 6?J Lic. Class -f _ FINAL �- Contractor'W64A�cf A6O•5. Date 79 BY ❑ I am exempt under Sec. I � B.&P.C. for this reason �� ) -� Plan check fee 4ti,3 Date: I PLUMBING PERMIT ISSUING FEE$ Signature � TOTAL FEE SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the �• ` 1 structure 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 o I A (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 i authorize representatives of this County to enter upon the above- entioned property for inspecYi purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �Si ature Pe itt Date j I %fVORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT. 20-0026 DPW 4/87 tis'.b hjsrrebFy, of4icm that'I have a certificate of consent to self in- 76A667A sure,or d certificate of Workers'Compensation Insurance,ora CE 817(REV.B/Bb) certified copy thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING r F1 Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET(TOILET) 60 NEAREST �p P BATH TUB CROSS ST /� CERTIFICATE OF EXEMPTION FROM WORKERS' r OWNER COMPENSATION INSURANCE SHOWER (This section need not be completed if the work involved by I �} MAIL / the permit is for one hundred dollars($100)or less.) LAVATORY V -ADDRESS • I certify that in the performance of the work for which this per- f. SINK LJ 6 CITY C1' tic TEL. NO. mit is issued, I shall not employ any person in any manner so �!^ as to become subject to the Workers'Compensation Laws. DISHWASHER _' CONTRACTOR Date Applicant CLOTHES WASHER 9. ADDRESS /4FX! L NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY APt TEL.NO. off sation provisions of the labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM 0- STATE A ly with such provisions or this permit shall be deemed revok- ed. WATER HEATER CLASS LICENSED CONTRACTORS DECLARATIONDISTRICT NO. rte P SSED B I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER rV GG11 and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINA VA ATION > CL feet. DAT a License Number Lic. Class a FIN � BY O Contractor DateUJI F- V I am exempt under Sec. B.&P.C. for this reason Pian check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE 98a3A SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Pion check applicant o o a o o 1 hereby affirm that I am exempt from the Contractor's License Name Low for the following reason (Section 7031.5, Business and j o o 9[L 5 0 Professions Code): Address F1 I, as owner of the property, will do the work and the City Tel. No. L structure is not intended or offered for sale(Section 7044, [(.a? 8 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 p 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 Signature of Permittee Date '• c WORKERS'COMPENSATION DECLARATION w her 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT }3`p, a{firm that I have o certificate of consent to self in- 76A667A sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86) certified copy thereof Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE / LOCALITY L...� Date ` Applicant �4/ WATER CLOSET(TOILET) 460 NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB a CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work Involved by MAIL the permit is for ono hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK CITY TEL. NO. Q�3 mit is issued, I shall not employ any person in any manner so G Q ?� as to become subject to the Workers'Compensation L DISHWASHER /, CONTRACTOR Date r-/ S Applicant ems` / CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of E ADDRESS 1 Z SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compe - CITY TEL. NO. cation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM ✓ � �� ly with such provisions or this permit shall be deemed revok- STATE L LIC. ed. WATER HEATER LICENSE NO. 6� CLASS LICENSED CONTRACTORS DECLARATION GAS SYSTEM OUTLETS DISTRICT& fi PRO SSED BY 1 hereby affirm that I am licensed under provisions of Chapter L (/j) 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER fe a, Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL �� VALI TION DATE O License Number Lic. ClassCi FI I= Contractor Date O b I am exempt under Sec. W B.&P.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE 9 8 a 4 A SINGLE FAMILY Plan applicant # 0 0 0 0 0 2 an ceca HOME OWNER-BUILDER DECLARATION pp I hereby affirm that I am exempt from the Contractor's License Name I 0 - 94.50 Law for the following reason (Section 7031.5, Business and o 00911,5050 Profe 'ions Code): Address LJ I as owner of the property, will do the work and the City Tel. No. 0614-88 4_88 structure is not intended or offered for sale(Section 7044, Business and Professions Code). io 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 State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned rqperty for inspection purposes. �' 1___.. !:� ' SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers'Compensation Insurance, CE 817(REV 10+81) or a certified copy thereof(Sec. 3800, Lab C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. i BUILDING /'�,� �5' �� -5 �� ❑ FOR APPLICANT TO FILL IN PRINT OR TYPE) c Certified copy is filed with the county building inspec- ADDRESS ,r, l tion department. NUMBER FIXTURE OR ITEM (� FEE LOCALITY � � C- Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER (This suction nood not bo complotod if the work involvod by MAIL SHOWER �j tho pormit is for ono hundrod dollars($100)or loss.) LAVATORY DDRESS 3 ! -3 E /%161SC i9%E e- I certify that in the performance of the work for which this /� permit is issued, I shall not employ any person in any manner SINK CITY V l d! £ y/ TEL. NO,) so as to become subject to the Workers'Compensat' n Laws. DISHWASHER 7 /� CONTRACTOR Date (o -2yApplicant v �'. ' CLOTHES WASHER , ADDRESS ��y ��22 & NOTICE TO APPLICANT: If, after akin this Certificate of rla Exemption, you should become subject to the Workers SWIMMING POOL RECEPTOR Compensation provisions of the Labor Codo, you must forth- CITY �7Lif/P/r� TEI. NO.�y`� -C/;C� P P y LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE ^� - LIC. G; deemed revoked. WATER HEATER LICENSE NO. J C/(-�'-�� CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS -� (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION ' 7 -3; DATE U License Number V(p 0`' 1.,Class -J FINAL Contractor Ylf��R "19-el Date / BY U I am exempt under Sec. B.BP.C. for this reason Plan check fee I ; Date: PLUMBING PERMIT ISSUING FEE$ ,>TI Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's licenso Address Law for the following reason (Section 7031.5, Business and Professions 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 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 State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above- entioned property for inspecti purposes X SEE REVERSE FOR EXPLANATORY LANGUAGE r' Si ature Peb itt Date