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Home My Public Portal About5221 SANTA ANITA AVE_Plumbing__ yy�� r 20.0026 DPW 9/89 �� Yd�WORKER'S COMPENSATION DECLARATION •I �l.reby.affirm that I have a certificate of consent to self insureI 76A667A APPLICATION FOR PLUMBING PERMIT, or a Cert lcate of Worker's Compensation Insurance, or a certified .copy there f Sec.3800 Lab.C.) `s 1� °•7 _ � COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Polidy No. ompany JL"JI Certified copy is hereby furnished. ADDRESS y 1 FOR APPLICANT TO FILL IN(PRINT OR TYPE) �r. 7• Certified copy is filed wfth the cou bu Ing In ecti pa ment. NUMBER FIXTURE OR ITEM ® FEE '�^ s LOCALITY Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WOR RS' BATH TUB CROSS ST. L� COMPENSATION INSURANCE ASSESSOR (This section.need no be completed if the work Involved by the SHOWER MAP,BOOK PAGE r PARCEL permit is for one hund d dollars($100)or less.) OWNER I certify that in the peri rmance of the work for which this permit LAVATORY Is issued. I shall not em toy any person In any manner so as to SINK MAIL �� I ADDRESS f become subject to the Wo ors.'Compensation Laws. DISWASHER CITY T4.NO.79 1 7 Date An Itcant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: I after making this Certificate of �01� Exemption,you should becomesSeeme the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS provisions of the Labor Code,yoforthwith comply with such U(/ provisions or this permit shall be Yauq ek SI. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION WATER HEATER CITY TEL.NO. a I hereby affirm that I am licensed under provisions of Chapter 8 STATELIC. (commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. . 7,5179L CLASS V Professions Code,and my license is in full force and effect. OUTLETS OVER DISTRICT NO. ROCESSED BY 7 5 PER SYSTEM ✓ � 4 Q License Numbe FINAL 3- ��/ VALIDATION a 'Contractor Date fn ❑ I am exempt under Sec. BY AL �j A - s 4 Z B.&P.C.for trmea-s7 G �pd Plan check fee , }7 1 + - � 1 ate: TES SignaturQ ' PLUMBING PERMIT ISSUING FEE$ AS _� TOTAL FEE 0--V TOTAL ❑ CHECK D 50 SINGLE FAMILY Plan check applicant r HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5, Business and Professions Address Code): 0003-00131 11/29/0 El 1, Tel.No. I,as owner of the property,will do the work and the structure 4 182 1 AIS 9:377 Is not Intended or offered for sale(Section 7044, Business and Professions Code). 01110. , 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 01111.Information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize rep ent tives of this County to enter upon the above-mentioned r�nyor inspection purp es. �} SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COVPEN$ATLON DECLARATIQN APPLICATION ION FOR PLUMBING PERMIT I hereby.offirm that I have a certificate of consent to self— 20-0626 DPW 8/87 insure, or a certificate of Workers'Compensation Insuhtnce, 76A667A or a certified coprthro{o�f/(Sec. 3800 Lob. j COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS Policy No. e"Qompany J ❑ Certified copy is hereby furnished. �' ' FOR APPLICANT TO FILL IN PRINT OR TYPE BUILDING I /" Certified copy is filed with 1 co my b di 1 spe ( I ADDRESS ito department. NUMBER FIXTURE OR ITEM FEE LOCALITY '() WATER CLOSET Date G N Appll4ant b NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS JF BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER : (This section n d not be completed If the work involved by SHOWER MAIL .6 Ud r the permit Is for no hundred dollars($100)or lest}.) LAVATORY ADDRESS V t�✓�% lr C :M I certify that to th erformance of the work for which this /�An permit is Issued,I sh I not employ any person in any manner SINK CITY vv�l TEL.NO so as to become subje t to the Workers'Compensation Laws. 7 V-66 DISHWASHER CONTRACTOR S_ � C Date App ant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, ter making this Certificate of Z S — SWIMMING POOL RECEPTOR Exemption, you should beco a subject to the Workers' TEL. NO• � � Compensation provisions of the bar Code, you must forth- LAWN SPRINKLER SYSTEM ft " _ with comply with such provisions r this permit shall be STATE' LIC. deemed revoked. WATER HEATER ILICENSE NO. L o /7 CLASS LICENSED CONTRACTORS DECLARATION DI TRICT NO. OC BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION License Num er Lic. Class_ DATE bJJJ.Jq0 0 FINAL � Contractor `' Date BY117- t / ❑ 8 I am ex mpt n er Sec. , (� LL8 BAP.C. for is r ason iD. Plan check fee � Cn Dar : PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License°v Law for the following reason (Section 7031.5, Business and Address Professions Code): City Tel. No. �ti1�7 4U°C0 ❑ I, as owner of the property, will do the work and the 1 ITE113 structure is not intended or offered for sale (Section 7044, Business and Professions Code). TOTAL 43 . 00 CONSTRUCTION LENDING AGENCY CHECK 43°0:: 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CHANE °(„O (Sec. 3097,Civ. C.). Lender's Name 0030-1001 5/11/91' Lender's Address ° r@@rtify that I have read this application and state that the ® 1�6+�7 1 AN ° , dye informatyon i�ct. I agree to comply with all County dinances and St e�is regulating Plumbing, and hereby th rize repre entativ s of this County to enter upon the bo a-menti d pe per f inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ature o Pe itte Dat