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Home My Public Portal About5246 SERENO DR_Plumbing__ WORKER S COMPENSATION DECLARATION 2ODD26 DRV 9/fit, 1 hereby affirm that I have a certificate of consent to self insure 76A11e7A APPLICATION FOR PLUMBING PERMIT LI or a certificate of Worker's Compensation Insurance, or a cartdied copy thereof(Sec 31300 Lab C) Pte, COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS { ' DEPT OF PUBLIC WORKS DIV ❑ Ceroned copy Is hereby furnished1 ❑ FOR APPLICANT TO FILL IN cerbned copy m need with the county b<dlang Inepeebm (PRINT°R TYPE) AD`�rSS2 PiTfj?d deparunent NUMBER FDITURE Off ITEM ® FEE LOCALITY Data Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS CROSS Si _ BATH TUB ASSESSOR (This section need61e-ln le-4 not be compllatsd INSURANCE theworkInvolved by ties SHOWER MAP ROOK G PAGE ,0 PARCEL Peron N for one hundred dollen(8100)or lap) OWNER .� r I certify that In the performance of the work for which this permit LAVATORY Is Issued I shall not employ any person In any manner so as to SINK CRESS ' become sub act to a Workers Com , tion JwYJa/./ _ Date 62� t 7PIIiI I'7t CLOTHES W CITY N TFL NO CLOTHES WASHER CONTRACTOR /r NOTIC TO PPLO ANT If eller making this Certlficet 1 (/rff Exempti0n you should become subject to the Workers Compennabton SWIMMING POOL RECEPTOR provisions of the Labor Code you must forthwith comply with such ADDRESS / prove ons or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CIT WATER Y c TEL NO a I hereby affirm that I am licensed under provisions of Chapter 0 STATE J (commencing with Section 7000) of Division 3 of the Business one OAe SYSTEM OUTLETS STATE rI.A,58 V LIC Professions Code and my license in In full force and effect V OUTLETS OVER DISTRICT NO PROCESSED BV 6 PER STEN Lk:enw Num LOO pass ` 3L convect P ��d�J.�iS �fALIDATION aW ❑ I ern exempt under Sec FINAL BY Z B AP C for this reason 00 TM] 12%.95 Date Plan check fee , 1 ITEMS Signature PLUMBING PERMIT ISSUING FEE 8 TOTAL 250 .65 ❑ TOTAL FEE rj CHECK 251].rbr5 SINGLE FAMILY Plan check applicantLiUt1�VG .!11 HOME OWNER BUILDER DECLARATION Name I hereby affirm that 1 am exempt from the Contractor a License Law f�e'following reason (Section 7031 S Business and Professions Address 5/W93 F1 as owner of the property will do the work and the structure city Tel No 9575 1 QM 9:19 is not intended or offered for sate(Section 7044 Business and Professions Code) ► CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the Woman"of the work for which this permit Is issued (Sec 3097 ON C) Lender s Name Lenders Address I certify that I have reed 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 thisounty to enter upon the above-mentioned pro amspection rpoeee SEE REVERSE FOR EXPLANATORY LANGUAGE TIL-7— 6 gnatura of PerrnRtee Date WORKERS'COMPENSATION DECLARATION App�ICATION FOR PLUMBING PERMIT I hereby, affem that I have a,certificate of consent to self in- 76A666 DTV aso 6A667A sure or a certificate oLWorken'Compenwhon Insurance,or a C�UI cq(tt(ted copy thereof(Sec` 3800, Lob C ) P3littcyy No 11"0 '� tompany �7� ylG COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ❑ Certified copy is hereby furnished ' J Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING department NUMBER FIXTURE OR nEm 9 FEE ADDRESS DDRE S L f Date Applicant WATER CLOSET(TOILET) NEARS ( M , CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST v.Y COMPENSATION INSURANCE ER (This section need not be completed if the work Involved by SHOWER OWNOWN MAIL the permlt Is for one hundred dollors($100)or loss) LAVATORY ADDRESS I certify that in The performance of the work for whichn per- SINK CITY _( TEL NO mit is issued I shall not employ any person in any mannw manner ysys" Zer as,to become subject to the Workers Compensation Laws DISHWASHER CONTRACTOR Date f, aftconter m CLOTHES WASHER ADDRESS NOTICE ,y AFRICAN If, after making this Workers to of Ex- SWIMMING POOL RECEPTOR emption,you should become subject ro the Workers Compen- Cltt TEL NO whon provmons of the Labor Code you must forthwith comp- Z, LAWN SPRINKLER SYSTEMS Q Ilywith such provisions or this permit shall be deemed revok- LSTI AIf G WATER HEATER LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY I herebyoff um that I am licensed under GAS SYSTEM OUTLETS elf pion 3 oft a Chapter l 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professiom Code, and my license is in full face and of 5 PER SYSTEM FINAL y, fact � HOSE BIB DATE 6� M44Dy, ON 6 License Number -y33 SSS Lic Class L yy�� FINAL �.�I�,-' :7.^�)0 Controctc;41 i-y'Q.t2r,- BY l ITE[') g 1 am exempt under Sec TOTAL 57 . 30'- B BP C for this reason ► CHE , 7,.7d l o Plan check fee Date PLUMBING PERMIT ISSUING FEE S tb f7 t� ]E .l1il Signature 3 � SINGLE FAMILY TOTAL FEE HOME OWNER BUILDER DECLARATION Plan check applicant QQ��f–Q[ID], 1/1:,J?4 1 hereby affem that I am exempt from the Contractor's License Name j 19? 1 FM 5:17 Law for the following reason (Section 7031 5, Business and Professions Code) Address 1, as owner of the property, will do the work and the City Tel No structure is not intended or offered for sole($echon 70u Business and Professions Code) Poo.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 ) Lenders Name Lender s Address I certify that I have read this application and state that the ► above infornwtion is correct I agree to comply with all County ordinances and State jaws regulating Plumbing and hereby authorize r r sent as of this County to enter upon the abov m p arty for inspection urp es s y G SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Perlmjtea I tDate