HomeMy Public PortalAbout5242 SERENO DR_Plumbing__ WOthat I have a ceSATIOR of consent to ' DPW else APPLICATION FOR PLUMBING PERMIT ,
1 hereby affirm that I have a certificate of weasel to Bell Insure
or a certificate Of Worker a Compensation Insurance or a certllled I I
copy thereof(Sec 3800 Lab C) 4 - — r
`
Policy No Campam COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS - L DEPT OF PUBLIC WORKS DIV
❑ CWWI;d copy Is hereby turn" �
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUNG '7
Cepartropy s filed elle Ne county Wildlmg Inspection ♦ f"
dePartrmry tem NUMBER FO(TIRiE OR REM O FEE LOCALITY ,
Data Applicant WATER CLOSET NEAREST -
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB cRoss ST G
COMPENSATION INSURANCE ASSESSOR
(This section need not be completedSHOWER
H the work Involved by the / SHOW - MAP BOOK d Q A PAGE �� .."'q
permit Is for one hundred dollen($100)w leu) LAVATORY OWNER Pr /r
I certify that in the performance of the work for which thlalpermit k1All
Is Issued I shall not employ any person In any manner u as to SSIK
became Subject t the Workers Comp Isaac Laws ADORES$
fj
��Itent V d/• DISWASHFA CITY ` H TEL NO
�te
NOTICE TO PPLICANT 11 alter making this Certificate 1 CLOTHES WASHER CONTRACTOq, r /"
Exemption you a Lab became YOU Mu to the Workers Comp SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code you must forthwith comply with such r
provlelons or this Permn shall be deemed revoked LAWN SPRINKLER SYSTEM r
LICENSED CONTRACTORS DECLARATION CRY s TEL NO '� (W }
1 hereby affirm that I am licensed under provisions of Chapter S WATER HEATER p-
(commencing with Section 7000)of Division 3 of the Business and CITY /J CS7j
Professions Codel end my Pica rise is In lull force and affect GAS SYSTEM OUTLETS LICENSE NO Q� CLASS (" �/
I—Number' LIC Clore `� OUTLETS OVER DISTRICT N
6 PER SYSTEM
2FINAL �O PROCESSED BY O
F
Camractor vmbi e �/R� a DATE (Q� y VALIDATION W
❑ I am exempt under SecBV F0IAL Z
h
B AP C Son Une reason A' S
Date Plan check fee , WCT.T
Signature PLUMBING PERMIT ISSUING FEE S e7 �JO7 �P�.E'c
fd
❑ TOTAL FEE jJ a. 1 ITU$
SINGLE FAMILY Plan �Plketlt TOTAL 250 . 65
HOME OWNER BUILDER DECLARATION , Namem - C�` I LJV.05
I hereby affirm that I aexempt from the Contractor a Lienee Lew f t
for the following reason (Section 7031 S Business and Professions Address
Code) - lHANE .00
ElCRY Tel No
I as owner of the property will do the work end tiro—1—
is not Intended or offered for sale(Section 7044 Business
and Professions Code) / WOO-0001 5/12/97,
CONSTRUCTION LENDING AGENCY _ 9574 1 AM 9:19
1 hereby affirm that there Is a construction lending agency for the r
performance of the work for which this permit la Issued(Sec 3087 '
Civ C)
Lender s Name m t
Lender Address , 1
I certify that I have read this application and state that the above ,
Information b correct I agree to comply with all County ordinances '
and State laws fegula Ing Plumbing and hereby authorize
representahvu of this unty to enter upon the above-mentloned ,
ProperLwiw Inspect! n rposaa SEE REVERSE FOR EXPLANATORY LANGUAGE '
Cw Sn 9
Igrtature of Permittee Date
WORKERS'COMpfNSA1ION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby, affihn that I have a Fenificate of consent to self in- 7e�46e7A�u�
sure,or o certificate of Workers'Compensation Insurance,ora
cent �Wed copy thereof (Sec 3800, Lab C )
Poli No ZZSL�EU' 1 Company I J DF� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS _
n certified copy is hereby furnished
( f-0R APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county budding inspection ADDRESS
de n ant NUMBER FIXTURE OR ttFA1 ® FEE
LocALrry
Date Applicant WATER CLOSET(TOILET). NEAREST Q�/�/7'�
CERTIFI TE OF EXEMPTION FROM WORKERS BATH TUB CIi055 ST
COMPENSATION INSURANCE SHOWER OWNER
(This secllon need not be completed if the work hwolved by ' MAIL
the jsermif Is for one hundred dollars($100)or less) LAVATORY ADDRESS v" alp YMTi yp/.br yr s
I certify that in the performance of the work for which this per SINK '�}}ss,� �f,A..t` �°°,�,�''''
mit is issued, I shall not employ any person in any manner so CITYOV- W4i j �4Frerft e. TEL NO zeiG-l
m to become subject to the Workers'Compensation Lows DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHERADDRESS
�I
NOTICE TO APPLICANT If after making this Certificate of Ex-
emption,you should become subject to the Workeri Compen- CITY TEL NO 7Tt�
sation Provisions of the Lahti Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS 7 TT
ly with such provisions or this permit shall be deemed revok- STATE LIC
ad WATER HEATER LICENSE NO 53?7>> CLASS G LSF
LICENSED CONTRACTORS DECLARATION DISTRICT NO eROCESSED BY
I hereby off irm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER J a
and Professions Code, and my license is in full force and of 5 PER SYSTEM FINAL VALIDATION c
fact G Z HOSE BIB DATE .E-
License Number Lic Clau
IL
FINAL 1 IT V
Contractor6W/— C.4�nll e_ L�/ / BY TOTAL 103 _ 65 c
I am exempt under Sec CHECK 101,�o V
i
B&P C for this reason Plan check fee ► CHANGE .11'.I
Dote PLUMBING PERMIT ISSUING FEE$ _
Signature TOTAL FEE 3 0000-0001 5/12/14
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Plan check applicant 5191 1 PM 5:17
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
structure is not intended or offered for sale(Section 7040,
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 3047, Civ C ) _
Lender s Name
t
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 la r ulanng Plumbing and hereby ' t
authorize re r a ve of this County t ant upon the
above pro r rinspection rpo s
(L FVf SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permi ee bate