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Home My Public Portal About5248 SERENO DR_Plumbing__ J WORKERS COMPENSATION DECLARATION dwmwx048137A alp APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a cenate of consent to sell es 7eAaa7A or a certificate of Worker a Compensation Insurance or a certified copy thereof(Sec 3300 Lab C) , Poky No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS - =- , DEPT OF PUBLIC WORKS DIV - . ❑ .Cerbhed copy is hereby fu nished ❑ FOR APPLICANT TO FELL IN(PRIM'OR TYPE) ADILDING DRESS n department NUMBER k flied with the county building nmpxtbn NVMB9i FUTURE OR RDA 9 LOCALITY < Dale ApplicamWATER CLOSET NEAREST CAST OS�tN CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB 8� !� Q COMPENSATION INSURANCE _ _ _ ASP BOOR PAGE PARCEL (This section need not be completed If the work Involved by the SHOWER perrind Is for one hundred dollers($100)or leu) LAVATORY OWNER L/�-. ( ✓ r I certiy that In the performance of the work for which this permit to issued 1 shall not employ any person in any manner so as to SINK MESS �� ( became sub to a Workers Compensation Lowe /� d jLAN CRY �-' TEL 40 Data Appllram R CONRiACTOq NOTICE TO APPLICANT If after making this Certificate ojif Ezempuon you should become subject to the Workers Compensation RECEPTOR ADDRESS / provisions of the Labor Code you must forthwith comply with such provisions of this permit shell be deemed revoked _ SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CRY C> TEL NO } I hereby affirm that I em licensed under provisions of Chapter a LICr� IL (commencing with Section 7000) of Division 3 of the Business and OUTLETS �L NSE NO CLASS ,Professions Code entl my license le In full force and effect _`/� //'� //— a�wT ,� rOLicerme Number J Uc Caes ✓ 6. �ay cc 3 DATE V .r ION FyHAL d connector _ ❑ I am exempt under Sec b� FINAL ,'10.6`Z B 8P C for the reason -- - 1 I103 Date Plan check feePoo. TOTAL 310 - 65 PLUMBING PERMIT ISSUING FEE$ �wj (,I 310.05 Signal" TOTAL FEE D, ❑ iFIAM� •00 SINGLE FAMILY Plan check applicant HOME OWNERam exa pt from C Contractors Nana I hereby affirm that am exempt from the Contractor a L tuneLew for the following reason (Section 7031 6 Business and Professions Address Coe) City Tel No 9676 1 Ah 9.213 I as owner of the property will do the work and the structure le,not Intended or offered for sale (Section 7011 Business and Professions Code) ' CONSTRUCTION LENDING AGENCY t 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) Lender a Name , Lender a Address 1 1 certify that I have read this application and state that the above - Poo.information Is correct I agree to comply with all County ordinances and State laws regulatl Plumbing end It authorize _ representatives of this Co.. ty to enter upon the above mentioned , Propertyf speclion s , SEE REVERSE FOR EXPLANATORY LANGUAGE �+'15di ci 9 - gneture Of Permittee Date WORKERS COMPENSATIONDECLARATION of RATION APPLICATION FOR PLUMBING PERMIT I h9refry, affirm that I have gcenifimte of consent to self in- p-0OZ6 DPW 4/90 sure,ora certificate of Workers Compensation Insurance,or a 76A667A �1 cerTifmd4opy thereof(Sec 3800 Lab C ) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS yluil Policy No ZZU. ompany Certified copy is hereby furnished BUILDING / a ❑ FOR APPLICANT TO FILL M IN(PRIOR TYPE) JL1/a Certified copy is filed with the county budding inspection ADDRESS !Jvtp depart enI NUMBER FIXTURE OR ITEM ® LOCALITY Dote Applicant WATER CLOSET(TOILET) CROSS 5<� ro^rM C RTI TE OF EXEMPTION FROM WORKERS' BATH TUB ' 7`VL COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed If the work Involved by ,NAIL the permit Is for one hundred dollars ($100)or less ) I LAVATORY ADDRESS rj pp I certify that in the performance of the work for which this per- SINK pry TEL NO mit Is issued, I shall not employ any person in any manner so — / as to become subject to the Workers Compensation Laws DISHWASHER carrrRAcroR PE Dote Applicant CLOTHES WASHER - 5� NOTICE TO APPLICANT If, after making this Certificate of Ex ADDRESS-7,YS- SWIMMING POO(RECEPTOR emption,you should become subject to the Workers Compen- CRY TEL NO cation provisions of the Labor Code,you must forthwith comp- Z LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shell be deemed revok- STATE DC ed WATER HEATER LICENSE NO 3SST CLASS 4�' L� LICENSED CONTRACTORS DECLARATION Ops SYSTEM OUTLETS DISTRICT NO PROCESSED BY affirm I hereby arm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION fact HOSE BIB DATE P License Number S33 Sia Lit: Class L 7-7r 5 C FINAL U ConhactorBi�� toBV faLtT.i Q I am exempt under Sec iz O 77 7 ��%il V B 8P C for this reason Plan check fee , 1 ITEM( LU Date PLUMBING PERMIT ISSUING FEE$ (9 p TOTAL 57 . 30 Signature SINGLE TOTAL FEE CH 57.�t0 HOME OWNER-BUILDER FAMILY UYs DECLARATION Plan check applicant G"GE •fl�l 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 WOO-WO1 !/12/Sit ❑ I as owner of the property, will do the work and the City Tel No 5193 1 5,2 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 _f (Sec 3097 Civ C ) _ t Lender s Name Lenders Address I certify that I have read th,s application and state that the , above information is correct I agree to comply with all County ' ordinances and State laws regulating Plumbing, and hereby - outhwize r re at s f this County to enter upon the abov p e for inspection purposes �zvSEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per ttee DotA