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Home My Public Portal About5211 SERENO DR_Plumbing__ WORKER S COMPENSATION DECLARATION 2'Z DPW I hereby affirm that I have a certificate of consent to self insure 7�_ A APPLICATION FOR PLUMBING PERMIT or a certificate of Worker a Compensation Insurance or •cortifled . t copy thereof(Sec 3800 Lab C) I = . - I COUNTY OF LOS-AN GELES DEPT-OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV — Policy No Company, ❑ Certified copy or hereby tummhetl / ` FOR APPLICANT TO FILL IN(PPoNT OR ryPt7 BUILDING - ❑ Certified copy Is filed with the county building inspection dapanmerd NUMBER FIXTURE OR ITEM M) FEE LOCALITY t , Date Applicant WATER CLOSET NEAREST CERTIFICATE OF PROMWORKERS BATH TUB CROSSST COMPENSATION INSURANCE K (This section nsstl not be compNtetl H the work Involved by the SHOWER MAP� PAGE Q PARCEL 0.;Q' ' permit Is for one hundred dollars($100)or leve) OWNER I certify that in the performance of the work for which this permit LAVATORY Is issued I shell not employ any person in any manner so as to _ SINK AD'LPIPM became subject to the Workers Compensatwn Laws Dale Applicant CLOTHES WASHER CONTRACTOR DISWASHEA r— TEL NO NOTICE TO APPLICANT If alter Making this Certllioete of _ Exemption you should become subject to the Workers Compensation SWIMMING POOL RECEPTOR ADDRESS provisions of the Labor Code YOU must forthwith comply With such provisions or this permit shall be deemed revoked 1 LAWN SPRINKLER SYSTEM } LICENSED CONTRACTORS DECLARATION Cin' TEL NO d I hereby affirm that I em licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000)of Division 3 of the Business and STATELIC C�71 • Prafesalons Code and my license is m OAS SYSTEM OUTLETS LICENSE NO CLASS Tull Torte entl effectS OVER I9T D1aCT NO PROCESSED BY SO PTR SYYSTEMt . O p OF License Number Lie ClaesFINAL O Dvi 2� -� n VALIDATION a Contracts Date CO 2 FlNAL � El em exempt under Sec BY / B 8P C for this reasat c Date Plan check fee ' Signal" PLUMBING PERMIT ISSUING FEES Iva i '1r-'• I AT ❑ SINGLE FAMILY Plan check applicant f T 1 CCI" HOME OWNER BUILDER DECLARATION Name - TOTAL _ 4 1 -8. —, I hereby affirm that I em exempt from the Contractor a License Law r for the following reason (Section 7031 5 Business and Professions Address Code) City, Tel No NAME ❑ 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) , T 0:0-01011 2/ CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the 7�r�t -r, !J 1 AM 9:*: perlormance of the work for which this permit Is Issued(Sec 3097 Civ C) I r - Lenders Name Lender a Address t I certify that I have read this application and state that the above , Information le correct I agree to comply with all County ordinances , and State laws regulating Plumbing en hereby authorize representatives of this County to ante po he ebov enllon I(( ny for inapectm purposes SEE REVERSE FOR EXPLANATORY LANGUAGE I� Signature of POrnifittepI di ate 3 � WORKER I have of consent to zomx DPW enm APPLICATION FOR PLUMBING PERMIT I�l.le Ilan diet I have a certificate of consent to self Insure 7NBB7A V a certificate of Worker a Compensation Insurance, or a certified copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV Policy No Company , (❑ Gentled copy Is hereby fumWlBd FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ❑ Certlhed copy is filed with the county building InspectionADDRESS department NUMBER FIXTURE OR ITEM 6 FEE LAITY Dale Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKMS' BATH NB CROSS •'/ COMPENSATION INSURANCE. ASSESSOR MAP BOOK PE0 PARCEL (This section need not be completed If the work Involved by the SHOWER H3 �� permit is for one hundred dollars(8100)w less) LAVATORY OWNER IS V v� I certify that in the performance of the work for which this permit -7 Is issued I shall not employ any person In any manner so as to1 e � P(� ADDRESS became eub)ect to the Workers Compensation n laws ^ Wfty I OISWASHFA Crry .. TF1 N 'Z Bete Applicant - CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT Iffafter making this Certificate of , Exemptlon you should become subject to the Workers Compensation SWIMMING POOL RECEPTOR ADDRESS .provisions of the Labor Code ,you must forthwith comply with such provisions or this permH shall be deemed revoked LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL NO } I hereby affirm that 1 em licensed under previsions of Chapter 9 WATER HEATER _ 888¢ (commencing with Section 7000)of Division 3 of the Business and STATE LIC Professions Code and my license is In full force and effect OAS SYSTEM OUTLETS LICENSE NO CLASS I OUTLETS OVER DISTRICT NO PROCESSED BY s PER SYSTEM Q�O 0 Lxxnae Number Lk: Cleve ATE 2 L VALIDATION In contractor Date co FI ❑ I am exempt under Sec t BYE ACCT.i ? B aP C for this reason 33u7 40.55 Date Plan check fee PLUMBING PERMIT ISSUING FEE S , 1 ITEMS _ ❑ TOTAL FEE p TOTAL 40 .EJc Plan check appllcard _ CHECK, r 0.65I� SINGLE FAMILY HOMEOWNER-BUILDER DECLARATION Name — 4TB9lVG I hereby affirm that I am exempt from the Contractor a License Law for the following reason (Section 7031 S Business and Professions Address Code) ❑ I u owner of the pr ary Tel No - 00�'1-�1 3/16/43 sped D will do the work end the structure Is not intended or offered for sale(Section 7044 Business �2 1 AM 442 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 3087 Civ C) , r Lenders Name ' r Lender a 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 Rate Tawe regulating Plumbing and hereby authorize rep r a aures of this County to enter upon the above mentioned pia r Ins ecaon Purposes f SEE REVERSE FOR EXPLANATORY LANGUAGE ' Signature a Perellttee 3 WOQKERS'COMPENSATION DECLARATION 20-OM DPW 4r90 APPLICATION FOR PLUMBING PERMIT I hereby, faffnm that I have a cernat consent to self m- 76Ay67A sure or a Lertificate of Worker Compensation ensahan Insurance or a � ylLJll certified copy thereof(Sec 3800, Lab C ) - COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS" Policy No Company N _ Certified copy is hereby furnished Certified co m filed with the court building me FOR APPLICANT TO FILL IN(PRIM TYPE) BUILDING copy county g pection ADDRESS .S y/1 �L�ReNA department NUMBER FIXTURE OR ITEM B FEE LOCALITY Date .Applicant WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST T Ar + COMPENSATION INSURANCE SHOWER _ _ OWNERUNCs SA'l✓ 1-411 (This sedlon need not be completed If the work Irrvohed 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- mit is issued, I shall not employ any person in any manner so SINK CITY �GM TEL NO as to become subject to the Workers Compensation Laws DISHWASHER J CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT If, after making this Cemftcote of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers Compen- CITY TEL NO sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE OC ed / WATER HEATER LICENSE NO �Cip/CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NOD By C I hereby affum 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 p C� VALIDATION fect / HOSE BIB DATE 0 License Number Lic Class d FINAL C V Contractor Date BY R O I am exempt under Sec f.7 B 8P C for this reason Plan check fee ► W d Date PLUMBING PERMIT ISSUING FEE E p'jb 0 Signature TOTAL FEE 3 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant � l _ I hereby offvm that I am exempt from the Contractor's License Name ALLT.i Law for the following reason (Section 7031 5, Business and Professions Cade) Address 33C4 1, as owner of the property, will do the work and the City Tel No 1 ITM,; structure is not intended or offered for sale(Section 7044, Business and Professions Code) ► TOTAL 196 e 3c CONSTRUCTION LENDING AGENCY '-HELY. 19'c-•�� I hereby affum that there is a construction lending agency for CHANGE •�� the performance of the work for which this permit is issued (Sec 3097 Civ C ) Lender s Name Lender's Address "76 1 AM 0.7" 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 pr gp or inspection pur ` SEE REVERSE FOR EXPLANATORY LANGUAGE fignamre oPPermitf6s IN Date " "S OMPENSATIONDECLARATaN " 76AW7A APPLICATION FOR PLUMBING PERMIT I herebtt affirm that I have a certificate of consent to self insure 78MB7A ora certificate of Worker a Comdensation Insurance a c Iliad - copy thereof(Sac 3800 Lab C) _ Policy No �27Z4t$3AZr r.y COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV ❑ C1110sd copy Is hereby furnished FOR APPUOANT TO FILL IN(PRINT OR TYPE) fiUILDINO C] CertifiedW ed copy ed with the county,building mspectm AGGRESS department NUMBER FD(TURE OR ITEM a FEE LOCALITY Date -Z-/Z- Awficam tYn. PtfG.h tis..` WATER CLOSET NEAREST 64 , CERTIFICATE OF EXEMPTION FROM WORKERS CROSS ST .017 COMPENSATION INSURANCE BATHTUB ASSESSOR pp (This section need not be completed N the work Involved by the SHOWER MAP BOOK PAGE 4110PARCEL Cid permit Is for ons hundred dollars(111100)of less) LAVATORY OWNER 6x1 1 certlty that In the performance of the work for which this permit Is IN Issued I shell not employ any person in any manner so as to SK /AMNL / MAILADDRESS become subject to the Workers Compensation Laws 7 /1 DISWASHER CITY L41'TELNo9 Z Date - Applicant CLOTHES WASHER NOTICE TO APPLICANT If after making this Certificate of I Exemption you should become subject to the Workers Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code you must furthwnh comply with such ADDRESS provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATIONWIxTY' v NO ZjL 93T } I hereby affirm that I am licensed under proswns of Chapter 9 WATER HEATER fl (commencing with Section 7000)of Division 3 of the Business and STATE LIC Professions Code and my license Is In full force and effect GAB SYSTEM OUTLETS LICENSE NO y /O CLASS /� b PER OUTLETS SS OVER TEM DISTRICT NO PROCESSED BY cc License Number*2/� LIC Clause — DP j_ FINAL-) q yl LU Contractor (oay.�rfa� �, 31 9 VALIDATION a. ❑ _ 1 sirI exempt urlder Sec BVD (�,d/ _ B AP C for this reason ate Plan Check fee Rbnseee PLUMBING PERMIT ISSUING FEE 3 FIT— TOTAL 3 , o ❑ FEE 5 SINGLE FAMILY Plan check aj>p0caftt _ _AC(T•T n HOME OWNER BUILDER DECLARATION Name 3307 39.3[1 I hereby affirm that I am exempt from the Contractor a License Lew H for the following reason(Section 7031 S Business and Prolesslons Address r 1 ITEM, Code) ❑ city Tel No TOTAL 39. 30 I as owner of the property will do me work and the structure Is not Intended or offered for sale(Section 7014 Business Poo. Professions Code) LECK 39..x] CONSTRUCTION LENDING AGENCY ' .00 I hereby affirm that there Is a construction lending agency for the _ performance o1 the work for which this permit In Issued(Sec 3087 Civ C) WOO-0001 ;` 2/ 2/93 Lender a Name I 7984 �1 AM 9:26 I Ladder 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 FtEVEASE FOR EXPLANATORY LANGUAGE Signature of Permittee Date I `