The URL can be used to link to this page

Home My Public Portal About5553-5553 1/2 SANTA ANITA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT `I hereby affirm that Nave a certificate of consent to self 76A667A insure, or a-certificate of Workers'Compensation Insurance, CE 817(REV. 10/81.) "or a certifie�d(yc.opy,thereof(Sec. ab. C.) f COUNTY OF LOS ANGELES BUILDING AND SAFETY 01 Policy Nor&Company �///7 Certified copy is hereby furnishe O fes/! .en BUILDING ger` f 4 Certified copy is filed with f e cau ilding ins ec FOR APPLICANT TO FILL IN(PRINT OR TYPE) J Y T,G P ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE , Date L dt Appli4an WATER CLOSET LOCALI r G 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($100)or less.) LAVATORY ADDRESS- • LJ, I certify that in the performance of the work for which this , permit is issued,I'shall not employ any person in any manner SINK _ CI TEL: -?7� so as to become subject to-the Workers'Compensation Laws. DISHWASHER r CONTRACTOR -e Date Applicant CLOTHES WASHER 41 ADDRE NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR &o$r t�P Exemption,• OR you should become subject to the Workers' CITY TEL. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM + with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATERLICENSE NO CLASSf'��7(r� LICENSED CONTRACTORS DECLARATION _ :W7 999 DIS T( f NO A PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS bzv (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 FINA. DATION t l [�! ?) DATELicense Number �?>?>q-7l Lic. Class Contractor Date 7 C ❑ FC- I am exempt under Sec. BA.P.C, for this reason 5 0 6 6 A LL Plan check fee G Date: PLUMBING PERMIT ISSUING FEE$ # 0 0 0 0 0 5 Cr Signature E_ TOTAL FEE Qd' 1 0 10 2 0 0 SINGLE FAMILY Plan check applicant 0 0 0 2 0 0 5 HOME OWNER-BUILDER DECLARATION Name 0 7. 17 _8 6 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 structure is not intended or offered for sale (Section 7044, Business and Professions Code). pop 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 1 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 at . ' •:-'WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT i fl I hereby affirm that,l 'ove a certificate of consent to self 76A667A insure, &,a•certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) or a certMed copy,thereof(Sec. 3800, Lab. C. � � COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No? 0. " 1 ❑5, Certified copy is hereby furnished. beim i BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Certified copy is filed with a conn Iding inspec- tion depprtment. NUMBER FIXTURE OR ITEM @ FEE LOCALITY C Date Applica WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB d— CROSS ST. COMPENSATION INSURANCE . OWNER (This section need not be completed If the work Involved by SHOWER the permit is for one hundred dollars($100)or less.) LAVATORY6:9MAIL -�7 ','j f �, ADDRESS �'./ s/`" �/�ir� !T L+ I certify that in the performance of the work for which this I �.`� t, permits issued, I shall not employ any person in any manner SINK _ CI "� ~ TEL. '7 so as to become subject to the Workers'Compensation Laws. DISHWASHER. a� / CONTRALTO Date Applicant CLOTHES WASHER (� ADDRESS , NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to- the Workers' CITY TEL. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. / deemed revoked. WATER HEATER LICENSE NO� CLASS e/� LICENSED CONTRACTORS DECLARATION ! DISTRICT NO. ESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS d � (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL � VALI TION liLic. Class DAT License Number �� CS`t C J XIN CsContractorA=Lr� �`� Date M I am exempt under Sec. Q • B.BP.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ CrCr Signature TOTAL FEE Plan check applicant A-5 0 b 7 A SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name # 0 0 0 0 0-5 1 hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and 1 ( 0 1 0 2 0 0 E]Professions Code): City Tel. No. 0 0 1 0 2 0 0 1, as owner of the property, will do the work and the N structure is not intended or offered for sale (Section 0 7. 1 7-86 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 Nome 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 a ove-me ' rte property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date