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HomeMy Public PortalAbout5551-5551 1/2 SANTA ANITA AVE_Plumbing__ ~ WORKERS'COMPENSAjION DECLARATION bA rim 'S11- LIC l ION FOR PLUMBING PERMS ' I he►ek. affirm thali I"have a certificate of consent to.self, 76A667A n insure,,or'a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof Sec. 38 Lab. C.) 4, COUNTY OF LOS ANGELES BUILDONG AND SAFETY 6. _ (� Policy `�,90 pany 1 ❑ Certified copy is hereby furnished-ter BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Certified copy is filed with t cou ' Ing inspec- /�^ tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY ��in /L C I Date . Appligan � —3 WATER CLOSET r NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUBCROSS ST. COMPENSATION INSURANCE o2 OWNE SHOWERMAIL f� (This section need not be completed if the work involved by �� j� the permit is for one hundred dollars($'.100)or less.) LAVATORY AD -7 6 (/C.J: � .D 171 •. I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner r SINK ;;:]CI TEL. so as to become subject to the Workers'Compensation Laws. DISHWASHER COIVTRA._C ef Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of ADDRES aj,_ e" Exemption; you should become subject to•the Workers' SWIMMING POOL RECEPTOR CITY TEL. Compensation provisions of the Labor Code, you must forth-P P Y lAV1/N SPRINKLER SYSTEM with comply with such provisions or this -permit shall be STATE. LIC. " deemed.revoked, WATER HEATER LICENSE NO. CLASS LICENSED GAS SYSTEM OUTLETS CONTRACTORS DECLARATION DISTRICT NO. P . ESSED BY TT I hereby affirm that I am licensed under provisions of Chapter 9 U (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL —J 7 LE VAAT6®619 DATE License Numbe s O Lic. Class Contractor r—rnm Date B (� ❑ I am exempt under Sec. V B.&P.C. for this reason Plan check fee OW. Date: co PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE R 5 0 7.2 A- SINGLE FAMILY Plan check applicant # 0 0 0 0 0 5 HOME OWNER-BUILDER DECLARATION. Name o 096.00 I hereby affirm that I am exempt from the Contractor's License Address Law,far the following reason Section 7031.5, Business and x Professions Code): City Tel. No. o 0 096 0'o 0 ❑ I, as owner of the property, will do the work and the ``\ r; ' U 7.,1 7,f6 8 6 structure is nbt intended or offered for sale (Section 7044, Business.and Professions Code). t' i 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 1 have read this application and stat&that the above information is correct. I agree to comply with all County ordinances andState laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the ove=m Medd property for inspection purposes. ASEE REVERSE FOR EXPLANATORY LANGUAGE 7 f Signature ittee of PermDate rWORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT I Hereby affirm that.�. hove a certificate of consent to self 76A667A F insuFe .r a certificpte of Workers'Compensation Insurance, CE 817(REV. 10/81.) uu ' or a certified copy thereof(Sec. 3 lab. C.) -0//17`�] COUNTY OF LOS ANGELES BUILDING AND SAFETY �^ Policy IVo�Compan / // / ❑ Certified copy is hereby furnisheJW�efiy - BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Certified copy is filed with t e count ding insp tion de art enf. NUMBER FIXTURE OR ITEM @ FEE LOCALITY (� Date Applican 9 WATER CLOSET NEAREST s� CROSS ST.TUB. , CERTIFICATE OF EXEMPTION FROM WORKERS' � BATH �, COMPENSATION INSURANCE -- SHOWER OAER�a 57 (This section need not be completed If the work Involved by MAIL the permit is for one hundred dollars($100)or less.) LAVATORY Y s ADDRESS I certify that in the performance of the work for which this / ` ' 97 A7, permit is issued, I shall not employ any person in any manner SINK _ CITE' TEL . (per so as to become subject to the Workers'Compensation Laws. / DISHWASHER CONTRACTOR Ira C_1�ane_ nLS0J1_S' Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If,-after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the.Labor Code, you must forth- CITY TEL..NOI with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE. �J LIC.' (d deemed revoked. WATER HEATER LICENSE NO. 4=0 CLASS, LICENSED CONTRACTORS DECLARATION DISTRICT NO.' P C ED BY I hereby affirm that I am licensed under provisions of Chapter 9 Z GAS SYSTEM OUTLETS (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER L1 and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL✓ VALID ION MCrc—Y C�/'� /_ DATE a License Number DD Lic.'Class —° of � FI L Contractojr/ '/ar-r©n-C Date (02 ❑ I am.-exempt under Sec. FC- C: ti B.BP.C.for this reason Plan check fee D5 0 7,3 A Z Date: PLUMBING PERMIT ISSUING FEE$ (//�, ' Signature / # o 0 0 0 0 5 s TOTAL FEE U/ ' Plan check applicant 1 009600 SINGLE FAMILY HOME.OWNER-BUILDER DECLARATION' Name 0.0096005 I hereby affirm that I am exempt from the Contractor's License Address 07, 17-86 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 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 repre°sentafives of this County to enter upon the c6ove-meettwied property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 1 Signature of Permittee Date