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Home My Public Portal About5549-5549 1/2 SANTA ANITA AVE_Plumbing__ :, .!.;WORKERS'COMPENSATION DECLARATION 20.0026 DPW 4/90 APPLICATION FOR PLUMBING PERMIT I hereby;%affirm that I have a certificate of consent to self in- 76A667A t sure,ora certificate of Workers'Compensation Insurance,or a f certified copy thereof(Sec. 3800, Lab. C.) � Policy No. Company CC5UNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) / 7 d✓ Certified copy is filed with the county building inspection ADDRESS� department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER.CLOSET(TOILET) Ddte Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. ., COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK CITY TEL.NO �.�� mit is issued, I shall not employ any person in any manner so as to become su ect to the Workers'Com ensation L ws. DISHWASHER CONTRACTOR Dof tg Applicant CLOTHES WASHER J ADDRESS NOTICE TO APPLICANT: If, after ma ing this Certifi ate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITYTEL.N 1 sation provisions of the Labor Code,you must forthwith comp- -LAWN SPRINKLER,SYSTEMS. ��- i ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. �- j� CLASS _ LICENSED CONTRACTORS DECLARATION. DISTRICT NO. t/J PROCESSEb BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM' OUTLETS 9(commencing with Section 7000)-of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION fect. HOSE BIB DATE License Number ✓��j/" Lic. Class FINfieAA �,�(/ � BY V Contractor Date cc El I am exempt under Sec. ��/ 1-6 Q B.&P.C. for this reason Plan check fee ® a Date: Signature PLUMBING PERMIT ISSUING FEE$ 7060 AM 9:35 z 1' (/v TOTAL FEE J L SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name Low for the following reason (Section 7031.5, Business and Professions Code): Address I, as owner of the property, will do the work and the City Tel. No. r 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 perty for inspection PAIrInyodes. /J SEE,REVERSE FOR EXPLANATORY LANGUAGE Signa of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT {� •• I hereby affirm-that'I}'hove a certificate of consent to self 76A667A LJ insure,, p certificate of Workers'Compensation Insurance, CE 8.17(REV. 10/81) r• or a cehifie�d co,+py�,thereof(Sec. 38 Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. _$�Company �� , ❑ Certified copy is hereby furnishe n � FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the couple ding insp ADDRESS tion department. NUMBER FIXTURE OR ITEM ® FEE �/' LOCALITY r Date Applicant ' WATER CLOSET d NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER ,/ (This section need not be completed if the work involved by SHOWER MAILW. '� /� the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS ^0 W. r � �o noes I certify that in the performance of the work for which this v �. permit is issued, I shall not employ any person in any manner SINK CIT TEL. 71, g 3 so as to become subject to the Workers'Compensation Laws., / DISHWASHER r CONTRACiO Date Applicant CLOTHES WASHER ADDRE NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR fr Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL. with comply with such provisions or this permit shall be. STATEJ LIC. e�• deemed revoked. WATER HEATER LICENSE N, �'• CLASS LICENSED CONTRACTORS DECLARATION / GAS SYSTEM OUTLETS Nom-/ P gE55ED'BY I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER• v. and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VA ATION g7gRf/ C1 DATE License Numbers d S`7 Lic. Class C �qy) . FINAL G Contractor Date jj�s BY fk ❑ I am exempt under Sec. C B.&P.C. for this reason Plan check feeCL Date: 250M A PLUMBING PERMIT ISSUING FEE$ 6 27 Z Signature # o 0 0 0 0 5 TOTAL FEE ) o o96,00 Plan check applicant SINGLE FAMILY o 0 096005 HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address 71 7g-86 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 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 Bove- d property for inspection purposes. ` SEE REVERSE FOR EXPLANATORY LANGUAGE - Signature of Permittee Date • WORKkRS'COMPENSATION DECLARATION ` APPLICATION FOR PFlaU®PI'11BOf1` G PERMT ' I hereby affirm that,l"have a certificate-of consent to self t 761667A 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 SAFE4Y Policy No. O 9 13 ompany c Certified copy is hereby furnishe'� e V\JM BUILDING �` � FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Certified copy is filed with t e co u ng inspec- �""` tion department. NUMBER FIXTURE OR ITEM FEE` LOCALITY C Date Applican WATER CLOSET NEAREST , ry BATH TUB CROSS ST. CERTIFICATE OF EXEMPTIQN FROM WORKERS' �.. COMPENSATION INSURANCE SHOWER OWNER �� '(This section need not be completed If the work involved by MAIL ;.I the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS 1 ,( �;•, . I certify that in the performance of the work for which this / permit is Issued,I shall not employ any person in any manner SINK _ CITY TEL.AI S �� so as to become subject to the Workers'Compensation Laws. DISHWASHER M r �-s �U ,,,C CONTRACTOR' ! A i% Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT:.If., after making this Certificate of SWIMMING POOL RECEPTOR Exemption, •you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- CITY '� TEL. NO J`I LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE -� LIC.. deemed revoked. WATER HEATER LICENSE NT /O CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO.. `„ PRQCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 15 PER SYSTEM FINAL r VALE ION (� DATE License Numbe Lic. Class L ' FEIN Contractor��s,n� Date ❑ I am exempt under Sec. ` B.BP.C. for this reason OLL. Plan check fee , Date: rl PLUMBING PERMIT ISSUING FEE$ Signature P` TOTAL FEE A507,OA Plan check.applicant SINGLE FAMILY # 0. 0 0 0 0 5 HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from•the Contractor's License 1.009600 Law for the following reason (Section 7031,5, Business and Address Professions Code): 0 0 0 9 b Q 0 5)' City• Tel. No. _ ❑ I, as owner of the property, will do the work and the () '] 17 8 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 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 01110 ordinances and State laws,regulating Plumbing, and hereby authorizes representatives of this County to enter upon the ab a-menti property for inspection purposes. 'SEE REVERSE FOR EXPLANATORY LANGUAGE � / ! J NLS_ • Signature of Permittee Date