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Home My Public Portal About5014 RYLAND AVE_Plumbing__ -WORKERS'COMPENSATION DECLARATION 20-0026 DPW 4/90 APPLMAYI®N FOR PLUMBING PERMIT ' I hezeby,aff7m that l have a Certificate of consent to self in- ,76A667A sure,ora Wrtificate of Workers'Compensation Insurance,or a- A.,. - n certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company ❑ Certified copy is hereby furnished. BUILDING ;1 copy' y g inspection FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS JV 4 Xyl/i Ala V , ,4MfI&CI T y Certified co is filed with the count building NUMBER FIXTURE OR ITEM @ FEE A LOCALITY d WATER CLOSET(TOILET) Dote Applicant v CROSS NEAREST L �r CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB COMPENSATION INSURANCE SHOWER OWNER kh (This section need not be completed if the work involved by '/ the permit is for one hundred dollars('$100)or less.) i9 MAIL LAVATORY ADDRESS51)/4-/ 1 yL/YNs7 411& I certify that in the performance of the work for which this per- o r��d'� mit is issued, I shall not employ any person in any manner so I SINK CITY TLNI t! �T y TEL. Noltq_ ,P/ as to become subject to the Workers'Compensation Laws. DISHWASHER � CONTRACTOR Date Applicant I CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY TEL.NO. sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. . I WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSEb BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ! r� 9(commencing with Section 7000)of Division 3 of the Business I OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION fect. HOS BIB DATE '"�j� --5 License Number Lic. Class i CL O FINAL ACCT 's' 0 Contractor Date BY °'u I am exempt under Sec. I 7 04 B.BP.C. for this reason I 1 ITEMS w Plan check fee �- ® Date: PLUMBING PERMIT ISSUING FEE$ 0 ® CASH TOTAL 204 4L, Signature I TOTAL FEE �U SINGLE FAMILY CHANGE °00 HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name 0 KAT511974 ( V15—v —TS-i-11?/ Gil1 Law for the following reason (Section 7031.5, Business and 0000-0001 11/ 1/95 Professions Code): Address �-()j�t 9 YLijAiD 11C- - 3108 1 PM 6o 16 �( I, as owner of the property, will do the work and the City ;c/(,f7CE C/? Tel. N919/-ell_IN/6 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 j the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). I Lender's Name I 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 property for inspection purposes. �� SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ature of P 1tte —� Date 76A667 17 11-49 APPLICATION FOR PERMIT DEPARTMENT Or D$ILDING AND SAFETY COUNTY OF LOS ANGELES WILLIAM J: FOX, CHIEF ENGINEER D O. GROUP . FOR APPLICANT TO FILL IN ]._f 49 mV i PLUMBER RECEIVED BY READY FOR DATE ISSUED , FIRST INSPECTION ADDRESS / BUILDING � CITY TEL.N.- p �(p 6 ADDRESS COUNTY _ LOCALITY LICENSE NO. !�// EXPIRES NEAREST PERMIT FEES CROSS ST. 41 NUMBER TYPE OF FIXTURE OR ITEM FEE OWNER MAIL WATER CLOSET(TOILET) 0.50 $ ADDRESS ��,Z (p_ BATH TUB @ 0.50 CITY TEL. No. SHOWER @ 0.50 1 HEREB ACKNOWLE GE THAT I HAVE READ THIS LAVATORY (WASH BASIN) 0.50 APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES KITCHEN SINK @ 0.50 AND STATE LAWS REGULATING PLUMBING. I CERTIFY THAT I POSSESS THE ABOVE VALID LOS LAUNDRY TUB OR TRAY @ 0.50 ANGELES COUNTY LICENSE, OR I AM THE LEGAL OWNER ::A OF THE RESIDENAL ES BED AB yE. GAS SYSTEM OUTLETS @ 0.50 (/f,� SIGNATURE OF 4. WATER HEATER 0.50 PERMITTEE SLOP SINK @ 0.501 INSPECTION RECORD FLOOR SINK @ 0.50 FLOOR DRAIN @ 0.50 DISHWASHER @ 0:50 DRINKING FOUNTAIN @ D.50 URINAL @ 0.50 J Q HOUSE SEWER @ 0.50 _Z MISCELLANEOUS O O APPROVALS DATE INSPEOTOR•S NAME ROUGH PLUMBING I �' GAS PIPING /A.0 ifs )� I GAB VENT CESSPOOL @ 1.430 CESSPOOL SEPTIC TANK: SEPTIC TANK DRAIN ( ) PIT ( ) @ 1.001 SEWER PERMIT I 1.00 GAS TEST �l UTILITY CO.NOTIFIED TOTAL FEE S FINAL eT� �'