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Home My Public Portal About5250 SERENO DR_Plumbing__ I WORKERS'COMPENSATION cateofRATON APPLICATION FOR PLUMBING PERMIT I hereby, affirm that 1 have q ceni6mte of consent to self m �6 DPW 4/90 sure ar a certificate of Workeri Compensation Insurance,ora 76A667A cenifLgd_copy thereof(Sec.3000, Lab C ) PorgWNoo ZZSb�—a Company [-;CI DW X416 COUNTY OF l05 ANGELES DEPT. OF PUBLIC WORKS ❑ Certified copy is hereby furnished Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN(PRINT OR TYPE) de men NUMBER FIXTURE OR ITEM b FEE LOCALITY Data ki Applicant �'LyiniL WATER CLOSET(TOILET) NEAREST G RTIFI TE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST COMPENSATION INSURANCE SHOWER OWNER ��a (This section nod not be contplefed If the work Involved by MAIL OxIt-the permit Is for one hundred dollars($100)or fess) LAVATORY ADDRESS I certify that in theperSINKformance of the work for which this per mit is issued, I shall not employ any person in any manner so CITY�. 'ILfi( TEL NO as to become subject to the Workers'Compensation Lows DISHWASHER CONTRACTOR1W,1 L Date Ap after mcant CLOTHES WASHER ADDRESS N-. NOTICE ,y APPLICANT If, after making to Certificate of Ex- SWIM4IING POOL RECEPTOR empn Pr you should become subject to the t forth 'Compen- CITY ,,u,s,�y A TEL NO ly with provisions of the Labor Code you must forthwith comp- LAWN SPRINKLER SYSTEMS P'WfN f'e Vd�T'r I�with such provisions or this permit shall be deemed revok- STATE r�(2 UC WATER HEATER LICENSE NO CLASS Z� LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ra p 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER O and Professions Code, and my license is In full force and ef- 5 PER SYSTEM fect FINAL VALIDATION HOSE BIB DATE Y License Number. ;�� Uc Class G Z� 04 GG�� FINAL ContractoreA� V "YTS ^'"•"Date 's _ BY Q I am exempt under Sec V B 8P C for this reason Plan check fee ► 5 W Date PLUMBING PERMIT ISSUING FEE f / �1-T' _ _ Signature TOTAL FEE 2 2 3303 7`.77 SINGLE FAMILY a, HOME OWNER-BUILDER DECLARATION Plan check applicant 1 ITM I hereby affirm that I am exempt from the Contractor's LicenseNama TOTAL 72 - 75 Law for the following reason (Section 7031 5, Business and c Professions Code) Address t_{'�'.Y� 7.2.75 1, as owner of the property will do the work and the City Tel No CHANGE 'U�l structure is not intended or offered for sale(Section 7044, Business and Professions Code) ,l CONSTRUCTION LENDING AGENCY - - t ► I)fl00-01701 5I12l rr 4 I hereby affirm that there Is a construction lending agency for 5187 1 Fin 5'1� the performance of the work for which this permit is issued (Sec 3097 Gv C ) Lender s Name 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 authonze r Pres f this County to enter upon the abov pro a or inspection p poses - S 7- SEE REVERSE FOR EXPLANATORY LANGUAGE Ignature of Permit e R S hereby affirm Oth�at I have a certificate DECLARATION self Insure _7 "D�Bf'g APPLICATION_ _ FOR PLUMBING PERMIT ll or a thereof of Worker s Compeneahon Ina tante or a certified - — I t copy thereat(Binet 9800 Lab C� Nowly-/ 37 � ,y41� (i � COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS _ ` DEPT OF PUBLIC WORKS DIV Policy Contact copy is hereby furnished y FOR APPLICANT TO FILL IN(PRINT OR TYPE) i ❑ cerb9etl papy la fled with he puny bw al m.pea0an` ADDRESS NUMBER FDRURE OR ITEM ® FEE LOCALITY �- Dele 4 Apple I WATER CLOSET NEAREST CS BT Q �/�'v�- CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB COMPENSATION INSURANCE ASSESSOR (This section Mad not be completed It the work Involved by the SHOWER MAP BOOK I I PAGE PARCEL pema Is for one hundred en or NM) LAVATORY OWNER L/L //� `�� VV c I certify that In the perlormanence off the the work for which this permit 1 Is Issued\I shall not employ any person In any manner so as to MNL a'�� (/ I N become a )act t the Workers Camp. ado I SINK ADDRESS �/ P DIBWASHFR cm ` �R dt✓f k TEL NO Applicant T` / CLOTHES WASHER ��R NOTI O APPLICANT If;alter making this Certihc• Exemptron You should become subject to the Workers Compenea on SWIMMING POOL RECEPTOR provisions of the Labor Code you must forthwith comply with ouch _ AI�ESS provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM �/ !� d STATE LIQ LICENSED CONTRACTORS DECLARATION - CRY 'T TEk NO I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER M /J (commencing with Section 7000)of Division 3 of the Business and pAS SYSTEM OUTLETS LICENSE NO CIA,T(t (,) Professions Cods and my license m in full farce and effect a ❑ e�C� Z DISTRICT NO _ 0ByGREY SPS1 26560ULicerroe Num Lk Clens OF DATE V4nT1 Canton P _ 65w65 a I am exempt under Sec FINAL CHE 265.652 ilo 00— B AP C for this reason i2 0 BY _ . Date Plan check fee _ L Signature PLUMBING PERMIT ISSUING FEE$ 2 b ► I]0010-10M 5/27/93 ❑ TOTAL FEE - Ao?(p 9978 1 AM 4:18 SINGLE FAMILY Plan Check applicant - - HOME OWNER BUILDER DECLARATION, Name - - -- - I hereby atom that I am exempt from the Contractor a License Law for the following reason (Section 7031 S Business and Professions Address Code) ❑ I as owner of thero CRY Tel No p petty will do the work end the etrocture to not Intended or offered for sale (Section 7044 Business and Professions Ccde) ► CONSTRUCTION LENDING AGENCY - \ r 1 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) Landera Name , Lender a Address I certify that I have read this application and state that the above information is correet I agree to comply with all County ordinances Poo.and State laws regulating Plumbing and hereby authorize- - representatives of this C unty to enter upon the above mentioned , propertyf dBpection p poses 8EE REVERSE FOR DCPLANATORY LANGUAGE .__ _ - _ Signature of Permittee Date