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Home My Public Portal About5256 SERENO DR_Plumbing__ WORKER'S COMPENSATION DECLARATION 260028 DPW li ` hereby affirm that I have a certlflwte of consent to self Insure _ 1SAWA' __ APPLICATION FOR PLUMBING PERMIT 11 or a certificate of Worker a Compensation Insurance or a certified - „- copy UereofLeD Cfi/ 1 �Qu�I�ny COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV Certified copy h hereby furnished BUILDING 6 E] ADDRESS FOR APPLICAfti TO FILL IN(PfaNT OR TYPE) Pj/t d Certified!copy Is filed wen the b i NUIVISP FIXTURE OR ITEM ® FEE LOCALITY C tr Date Applicant WATER CLOSET NEAREST CROSSST CE TE OF EXEMPTION FROM WORKERS BATH TUB COMPENSATION INSURANCE - ASSESSOR (This section head not be completed If the work Involved by the SHOWER t MAP BOOK ,`� ADE PARCEL' - permit Is for ores hundred defiers($100)or leu) LAVATORY OWNER I certify that In the performance of the work for which this permit r Is Issued I shall not employ any person In any Aboof neer so as to y7NK - CRESS v n f n become b)yyecl t thApo Workers Compo Iso ' Dale O� DISWASHFR CITY f� TEL NO NOTICE TOA PLICANT If a ter making this Certificate of CLOTHES WASHER / CONTRACTOR Exemption,you should became subject to the Workers'Compensation BWMUM POOL RECEPTOR prowaons of the Labor Code you must forthwith comply wah such ADDRESS :0- Provisions or this permit shell be doomed revoked LAWN SPRMIO.FA 6'YeTEII _ e t LICENSED CONTRACTORS DECLARATION CITY TEL Q r TNO ! a it I hereby affirm that 1 am licensed under provisions of Chapter 9 WATER NEATER (commencing with Section 7000)of Division 3 of the Business and STATE 8 Professions Cotler d my license u In full force and eH GAS�'B� - LICENSE OUTLETS OUTLETS OVER pDWRIct NO PROCESSED BY Q ()/ , 6 PER VST .�+�0 O �(rTs'a Q License Number LIC Clem C + C D VX T .65 a Convector Dale I. Tn ❑ I am exempt under Sec _ gFI AL TOTAL 280-65Z B$P C for this reason CHECK 2W.65 - Plan check fee SrgnSignatureDate PLUMBING PERMIT ISSUING FEE$ 6110. C I .al ❑ TOTAL FEE 6 ' M-WO1 5/27/93 Plan check applicant 9982 1 Ah 9:19 SINGLE FAMILY HOME OWNER BUILDER DECLARATION Name I hereby affirm that I em exempt from the Contractors License Law _ for the following reason (Section 7031 5 BValmass and Prafaes on. Address Code) El (sty Tel No I u Dene o1 the property,w10 do the work and the structure _ Is not Intended or offered for ule (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 3097 - Civ C) Larder a Name Larder a Address I certify that f have read this application and state that the above - - Pol.Information Is correct I agree to comply with all County ordinances and State laws regulating Plumbing an arse authorize representatives of le County to enter upon t e mentioned P Y for Ina so on purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature Of Pe7mtttee Dde WORKERS COMPENSATION DECLARATION 200M DPW.� APPLICATION FOR PLUMBING PERMIT I hereby, affirm that I have avegq certificate at consent t self m- 76A667A , sure or a certificate of Workers Compensation Insurance, ce,ora certified copy thereof fSec 3800, Lab C ) Pol'cy-No 7-2110`1;12 lCompany 411101 � COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ❑ Certified copy is hereby furnished ❑ Certified co is filed with the tours building m FOR APPLICANT TO FILL IN(PRIM OR TYPE) BUILDING PY county g spection ADDRESS SL 1P.. d part tint a./ NUMBER FIXTURE OR ITEM 6 FEELOCAL -rvtr� G Date 1 C 7 Applicant �'sVF rlrr fAs«�/ WATER CLOSET(TOILET) NEAREST- r (� , CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS Sr COMPENSATION INSURANCE SHOWER OWNER _ (ThIs section need not be wtnpletethew d If twork Inlsed by the parnsif Is for one hundred dollars($100)or less) LAVATORY ADDIRESS FLI I certify that in the performom,:e of the work for which this per- mit is issued, I shall not employ any person in any manner so SINK CITY , 457AM 4AS*V6,J TEL NO m to become subject to the Workers Compensation Laws DISHWASHER CONTRACTOR�/k .� (,ANAs 44P6 Date Applicant 1. CLOTHES WASHER ADDRESS ) e�& . & q NOTICE TO APPLICANT If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR rf/•m's /m+ emotion you should become subject to the Workers'Compen- Cltt A41"('PoA - TEL NO whin provisions of the Lahr Code you must forthwith comp- LAWN SPRINKLER SYSTEMS �/ Iwith such provisions or this permit shall be deemed revok STATEL1C WATER HEATER LICENSE NO S3zSSS CLASS ?.a- LICENSED CONTRACTORS DECLARATION DISTRICT NO / PROCESSED By I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �O 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code and my license is in full force and of- 5 PER SYSTEM FINAL RATION Fact HOSE BIB DATE License Number._ .53.' Lic Class :r3 •�LiIL U Contractor Date BY FINAL 1 ITERS ❑ am exempt under Sec TOTAL S -�?Q o B 8P C for this reason Plan check fee NECK 8S Cw, CHANGE •D 16 Date PLUMBING PERMIT ISSUING FEE$ Z Signature TOTAL FEE SINGLE FAMILY Plan check applicant HOME OWNER BUILDER DECLARATION LI hereby affirm that I am exempt from the Contractor's License Name 519r% 1 M r} L. ow for the following reason (Section 7031 5, Business and - Professions Code) Address J ❑ Tel No I as owner of the property, will do the work and the City � structure is not intended or offered for sole(Section 70x1 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 n issued (Sec 3097, Civ 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 lows regulating Plumbing, and hereby authorize represyot tiv f this County to enter upon the abo m nSd p op for inspection pis poses S /� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per m D to