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Home My Public Portal About5545-5545 1/2 SANTA ANITA AVE_Plumbing__ • WORKERS'COMPENSATION DECLARATION A r��s�tl ®ice F®� PLUMBING PERMIT JI h0iebyaaffirm"that I'have a certificate of consent to self 176A667A `Insure,•or'b certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) �J 4 ora.certified copy thereof(Sec. 3 ab.v /Alwyam c COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ��y��.n J fl ❑ Certified copy is hereby furnished.7,A P_M4M FOR APPLICANT TO FILL IN(.PRINT OR TYPE) BUILDING S (15/Certified copy is filed with the county building i.nspec- ADDRESS ^.tion dyartrnt. NUMBER FIXTURE OR ITEM i14 .FEE LOCALITY Date Z 1i Appligant WATER.CLOSET '— NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' ; BATH TUB 1 CROSS ST.. COMPENSATION INSURANCE .�+ SHOWER OWNER; (Jn s (This section need not be completed if the work'involved by MAIL /�7 the permit is For one hundred dollars($100)or less.) LAVATORY — MAILADD •/'/ %�L�L�. •/ I certify that in'the performance of the work for which this \ ��=; `• +� permit.is issued, I shall not employ any person in any manner SINK CIN ` / ," TEL. NO �� so as to become.subject to the Workers'Compensation Laws. / DISHWASHER CONTRACTOR "C) S Date Applicant CLOTHES WASHER ADDRE n LZ A7 rr NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR �� Exemption, you should become subject to the Workers' CITY 12Uk TEL. NO. �� QR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM is with comply.with such provisions or this permit shall be STATE / i LIC. deemed revoked. WATER.HEATER LICENSE NO `-7 CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. P OCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ` (commencing with Section 7000)of Division 3 of the Business' OUTLETS OVER i ZI and Professions Code,aand my license is in full force and effect. 5 PER SYSTEM FINAL VA ATION License Numbe I ag` Lic. Class DATE C FINS ;15074A Contractor Mid Y-f,r ldh'f Date # 0 0 0 0 0 5 Q ❑ I am exempt under Sec. C 1009600 B.&P,C. for this reason 4 Plan check fee o96,001 a Date: V PLUMBING PERMIT ISSUING FEE$ �. Signature 07. 1 7 1 8 6 TOTAL FEE Plan check applicant SINGLE FAMILY 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 Te). 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 ove-ment' o property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date ) WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMOT I hereby affirm thdt f have a certificate of consent to self 76A667A insure,.-or;a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) LLLJJJ + or.a ce7tified copy thereof(Sec. 3BQbLab. C.� /� I��//,� &7 COUNTY OF LOS ANGELES BUILDING AND SAFETY r —�3J'<�� P y Policy No. om an _ ❑ Certified copy is hereby furnishe e,24/ 1 �� FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING J i ^� An Certified copy is filed with the count ding inspec- ADDRESS `7 6' tion department. NUMBER FIXTURE OR ITEM @ .FEE LOCALITY ��P. ` �� Date Applican WATER CLOSET 1171 NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB _ CROSS ST. COMPENSATION INSURANCESHOWER OWNER^ 7 (This section need not be completed if the work Involved by , the permit is for one hundred dollars($100)or less.) LAVATORY MAIL n I certify that ADDRESS in the performance of the work for which this 4> permit is issued, I shall not employ any person in any manner SINK _ CIT A TEL. N06-1(,_ so as to become subject to the Workers'Compensation Laws. DISHWASHERCONT RACTOR` e•r1n !� Date Applicant CLOTHES WASHER ADDRES %& NOTICE TO APPLICANT: If, after making this Certificate of IDwer Azusa, Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY" TEL: N (/` with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STALIC. CL deemed revoked. WATER HEATER LICENSE N ^'a CLASS "7irJ LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR CESSED BY I hereby affirm that I am licensed under pfovisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER L and Professions Code,and my license 9s in full force a d effect. 5 PER SYSTEM = FINAL TION DATE License Numb ? I/ Lia Classcyap C FI C; Contractor rOnSo- Date B ❑ I am exempt under Sec. C B,BP.C. for this reason 5 7 Jr A a Plan check fee Date: er PLUMBING PERMIT ISSUING FEE$ ®' # a o a o 05 Signature � TOTAL FEE ) o o 9,600 SINGLE FAMILY, Plan check applicant o o 0 9 6 0 0 5 U HOME OWNER-BUILDER DECLARATION Name 07. 1 7—, 86 1 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 (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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date V