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Home My Public Portal About5252 SERENO DR_Plumbing__ WORKERS'COMPENSATION DECLARATIONconsent to APPLICATION FOR PLUMBING PERMIT I hereby, affirm that I have q certificate offconsent to self in- 204M DPW v� /-1 sure or o certificate of Workers'Compensation Insurance,or o 76A667A /'I ce copy thereof(Sec 3800 Lob C ) [,lull Po icy No lj- OlCompany A19IfJ �MiIC� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Certified copy is hereby furnished ❑ FOR AFRICAN TO FILL IN(PRIM OR TYPE) BUILDING Certified copy a filed with'the county building inspection ADDRESS 5z S`L �r0 b k- de72,;) a men NUMBER FIXTURE OR ITEM Q FEE Loculry meritivis Date Z Applicant 9iI�YZW WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST COMPENSATION INSURANCE SHOWER OWNER _ (This section need not be completed If the work Involved by MAIL Y the permit Is for one hundred dollen($100)or less) LAVATORY ADDRESS v I certify that in the performance of the work for which this per- SINK Clry mit is issued, I shall not employ any person in any monner so , 5&+g- TEL NO rrel�rpy� _I�l as to become subject to the Workers'Compensation Lows DISHWASHER e_�--,AVS L�.PS-r CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS U,4;- NOTICE TO APPLICANT If after making this Certificate of Ex- 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- `� STATELIC ed WATER HEATER LICENSE NO 15-3-5 SSV CIASS G- Z.� LICENSED CONTRACTORS DECLARATION - DISTRICT NO PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS STEM OUTLETS O p 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER I, J a and Professions Code, and my license is in full force and ef- S PER SYSTEM FINAL aArLIT DATION fect License NumberHOSE BIB DATE TO> _ �v!�ry/�� p� �,— FINAL 1 ITEM () Contractor !i°L*rDSU to 4—y FBY I 1 am exempt under Sec TOTAL 33 - 20e BBPC fee this reason Plan check fee CHECK "''•2id Date , i_HANGE PLUMBING PERMIT ISSUING FEE f p Signature s` TOTAL FEE G SINGOOOO—OU01 5/12/9,tHOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I exempt from the Contractors License Name `194 1 PM 12 Law for the followingg r 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 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 (Sec 3)97, Gv C ) Lender s Name Lender's Address _ t I certify that I have read this application and state that the - ► above information is correct I agree to comply with all County _ a and State to egulatmg Plumbing, and hereby ep ti this County to enter upon the p ty or Inspection put ossa r a SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Perm to yte WORKER SCOMPce�SAT10NDECLARATION fconsentto DPW glee APPLICATION FOR PLUMBING PERMIT I hereby ef)um that I have a certificate of consent to self Insure TAM87A or a certificate of Worker s Compensetlun Insurance or a certified - - copy lhereo ( 3 0 Lab ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV Policy I, x hued TJ :w0�d py m fled withCertified copy m hereby furnished /❑ FOR APPLICANT TO Fal IN(PRIM 'PLOCALITYOR TYPE) 1 Z S .�tthe ")AAAI f"/�ert NUMBER FD(TURE OR ITEM ® FEE LOCAL .� Date AEXE WATER CLOSET CROSS ST CO g CERTIFICATE OF EXEMPP TION FROM WORKERS'' COMPENSATN INSURANCE BATH TU8 MAP BOOK PAGE PARCEL , (This section need not be completed If the work Involved by the SHOWER _ � f/ t PeIs for one hundred dolWe($100)or less 1 LAVATORY - � (.,al- I certify that In the performance of the work for which this permit oljl Is Issued I shell not employ any person in any manner so as to SINK _ REBS _ f n _ become subject to the Workers Compensation Laws DISWA3tIEFi CRY �.K. Data Applicant i CLOTHES WASHER NOTICE TO APPLICANT If after making this Certificate of CONTRACTOR Exemption,you should become subject to the Workers Compensation SWIMMING POOL RECEPTOR provlalons of the Labor Code you must forthwith comply with such ADORF� I W I I A6 provisions or this permit shell be deemed revoked LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CRY x s TEL NO I hereby affirm that I am licensed under provisions of Chapter 9, WATER HEATER a LICENSE NO CLASS(commencing with Section 7000) of Division S of the Business and STATE _ r }V( Professions Code and my license is In full force and affect (IAS SYSTEM OUTLETS OUTLETS OVER DISTRICT NO PROCESSED BY t 6 PER SYSTEIj License Number&.q/ Luc Class � SDATE '''//)�D� V DATION Contractor LI- d ❑ I am exempt under Sec FINAL ACCT.: ? B$P C for this reason 3303 265.65 Date Plan check fee 100. 1 ITEMS SignaturePLUMBING PERMIT ISSUING FEE$ 1 F-1SINGLE FEE 1 �TLtO�TAL 265.65 SINGLE FAMILY PlanaGI aleck applicant ECK 265.65 HOME OWNER BUILDER DECLARATION Name -- _ CNANGE .00 I hereby affirm that I em exempt from the Contractor a License Law - for the following reaaon(Section 7031 6 Business and Professions Address Code) Elas owner of the property,will do the work slid the structure city Tel "° D -O(%J1 5/27!93' Is not Intended or offered for sale(Section 7064 Business _ 9981 1 AM 9:19 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 3097, r t Cm C) Lender a Name Lender s Address I certify that I have read this application and state that the above , information is correct 1 agree to comply with all County ordinances and Stele laws regulating Plumbing and hereby authorize representatives of this iounty to enter upon the a ve mentioned 9 Props r en inspect osea n p rpSEE REVERSE FOR EXPLANATORY LANGUAGE Signature Of rmlttee Date