HomeMy Public PortalAbout5258 SERENO DR_Plumbing__ ION
WORKER I have
of consent
756AW DPW�e/� APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certlticete of consent to sell insure 7MeB7A
or a certificate of Worker a Compensation Inyurance or a certified
copy Thereof( L b� r
Policy N D/ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
❑ Ceruhed copy is hereby furnished '
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
❑ spy le flbtl with iM my Ilct ADDRESS
NUMBER FDGURE OR ITEM O FEE LOCALITY
Date ApPlxerlt WATER CLOSET LOCALI `•
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB NCROSSST
EAREST
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed If the Mork Involved by the SHOWER
MAP BOOK IPAPE r I PARCEL
permit Is for one hundred dollars($100)or leu) LAVATORY OWNER v '
I certify that in the performance of the work for which this permit MAIL t
Is Issued I shall not employ any person In any manner so as to SINK ADDRESS
became b)ect t he Workers Compere tion La a -
DISWASHf3i r CITY
Data / �� Appt • CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT If after making this Cerliicale,of
Exemption you should become subject to the Workers Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code You must forthwith comply With such ADDRESS ( t
prmislons or this permit shell be doomed revoked LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY N TEL NO
I hereby affirm that I am licensed under provisions of Chapter g WATER HEATER /� a
(commencing with Section 7000)of Division's of the Business and GS SYSTEM OUR.ETS STATE NOLl YU 91\ LUSS C C87
Professions Code and my license is In full force antl effect Is
OUTLETS OVER DISTRICT NO P-ROC_ESSED BY cc
6 PER SYSTEM p stJ
License Number Uc Clam v DO V
nTE c LIDATION nw
Contractor Date ILI .r (A
ElI am exempt undx Sec RIIAL 265 KI Z
-B SP C for this ree,an 1 ITEhS
Date Plan check fee _ _
PLUMBING PERMIT ISSUING FEE S b� TOTAL 265. 65
Signature - - -
❑ TOTAL FEE DECK 7��tsv,A - 265.65SINGLE FAMILY Plan check applicant l.f�� s VLI
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I em exempt from the Contractor a License Law
for the following reason(Section 7031 6 Business and Professions Address t 13000-0001 5/27/Tl
Code)
❑ City Tel No - - - 99ED 1 AN 9'1,'
1,as owner of the property will do the work and the structure
Is not Intended or offered for sale(Section 7011 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 3087 l
Civ C)
Lender a Name
Lenders 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 eg ulaU ng Plumbing and hereby authorize
representetirm 01 ihls County to enter upon t above entloned
pro r ins tion purposes BEE REVERSE FOR EXPLANATORY LANGUAGE
�a 43
Sipneture of Rtee- e .
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
1 hereby, affirm thQt I have o certificate of consent to self m- 2Da026 DRV 390 '
sure,or a certificate of Workers Compensation Insurance,or 76A667A a '
certtiifi��copy theasof (Sec 3800 Lob C ) ,
Po Icl-y rho u'ZSo97-'OlCompa'A0(D6wT EPC*I* COUNTY OF LOS11 ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished
FOR APPUCAM TO FILL IN(PRINT OR TYPE) BUILDING Certified5 58 p�Certifieda b
Certified copy led with the county budding impaction ® ADDRESS J Z'O
de me NUMBER FIXTURE OR ITEM LOCALITY
Date 4 Applicant -�'fC L '� WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST n'a�i'��m^cFr •Y z
COMPENSATION INSURANCE SHOWER - OWNER
(This section need not be completed H the work Involved by
the permit Is for one hundred dollars($100)or Ins) LAVATORY rDDRESS
1 certify that in the performance of the work for which this per-
mit is issued I shall not employ any person in any manner so SINK CI TIM � ��/� TEL NO ...�t'
os to become subject to the Worken Compensation Laws
DISHWASHER CONTRACTOR Lj�Arb54AJ�1G -
Data Applicant CLOTHES WASHER
NOTICE TO APPLICANT If, after making this Certificate of Ex- ADDRESS
emption you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR
whOn provisions of the Labor C CRV TEL NO e you must forthwith comp- LAWN SPRINKLER SYSTEMS �-
ly with such provisions or this permit shall be deemed revok STATE �S IC C.-.2
ed WATER HEATER LICENSE NO
LICENSED CONTRACTORS DECLARATION DISTRICT PROCESSED BV
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS O
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER O
and Professions Code, and my license is in full force and ef- 5PERR SYSTEM FI
EB
FINAL VALIDATION
/ _'y
L,cense Number. ��s 55'5 L,,: m Class _ _ c 0
,,uu�� �����iscc FINAL 0
Contracto0'*VT�;'-_%ate_ , BY ACCT.4 R
O
I am exempt under Sec
B 8P C for this reason Plan check fee ► 1 ITEM= IL
IL
Date PLUMBING PERMIT ISSUING FEE$ CA6 TOTAL 72 . 751
Signature TOTAL FEE _ CHECK 7:.75
SINGLE FAMILY Plan check applicant ,I il]
HOME OWNER-BUILDER DECLARATION pp i �HAFIUE
I hereby affirm that I am exempt from the Contractors License Name _
Law for the following reason (Section 7031 5, Business andIU-[{[f�i 5/12/9't
Professions Code) Address
1, as owner of the property will do the work and the City Tel No 1136 1 FM 5'15
structure is not intended or offered for sale(Section 7044 .
Business and Professions Code)
CONSTRUCTION LENDING AGENCY _ ► `
1 hereby offum that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec 3W7 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 laws regulating Plumbing and hereby
authorizer re a as this County to enter upon the
abov - e pro f inspection pr- 11
s
Z, 1 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permit c4te