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Home My Public Portal About5260 SERENO DR_Plumbing__ WORKER gave a CeSATION DECLARATION 76A OP"'Bl� APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certllkele of consent to self Insure or a certificate of Worker a Compensation I yrence or a certified - copy thereof(Sec 3800 eb Policy Noir MW y �( COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV Certified copy 1.hereby hunnhed - J ❑ le filed with thety-ruptv;"MI, f-0R APPLICANT ro FILL IN(PRINT OR TYPE) ADDRING ESS 0 TT 0 ADORES$ I NUMBER FUTURE OR REIA6 � LOCALffY.Deis Applkem WATER CLOSET � NEAREST '1 CERTIFICATE OF EXEMPTION FROM NrOPoa=R.S BATH TLB CROSS ST COMPENSATION INSURANCE - ASSESSOR { (This section need not be completed If the wort Involved by the SHOWER MAP BOOK - PAGE PARCEL Permit Is for one hundred dollars(8100)or less) _ OWNER R Of I certify that In the performance of the work for which this permit LAVATORY V Is issued 1 shall not employ any person In any anner so as to SINK MAIL A�1 became a act to the Workers Com w - ADDRESS r, / DISWASHER CRYAk rjk ) L NO Date Z App / NOTICE O A PLICANT If eller CLOTHES WASHER AOR I making this Certificate of U►'✓) � YI Exemptlon you should become Subject to the Workers'Compensation SWIMMING POOL RECEPTOR provolone of the Labor Code you must forthwith Comply with Such ADDRESS �� provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION WATER HEATER CfTV rryY` it TEL I hereby affirm that I em licensed under provisions of Chapter 9 STATNO d f E LIC 8 (commencing with Section 7000)of Diwalon 3 of the Business and' OAS SYSTEM OUTLETS UCENSE NO CLASS Professions Code and my license Is In full force and effect OUTLETS OVER DISTRICT NO PROCESSED BY Q ,L1r-/Gyr' A5 PER SV Lkrense Number `r' ` 1 Lc flees 03L / C Fl 0 U J e ten Date DATE VV/ LIDATION a attar AGGT.4 z ❑ I am exempt Under Sec FINAL UT B AP C far this reason ' t 33OJ 325.65 Date Plan check fee 1 ITEMS PLUM&NG PERMIT ISSUING FEE$ TOTAL 325-65 ❑ - TOTAL FEE MCK 325.65 SINGLE FAMILY Plan check applicant _ r. .00 HOME OWNER BUILDER DECLARATION Name I hereby affirm that 1 am exempt from the Contractor•License Law MOD— nn for the following reason (Section 7031 5 Business and Professors Address _ MOD-0nW l 5/27/93 Code) City ❑ 1 as owner of the pro Tel No 9979 '1 9 o is party MII do the wart end the structure le not Intended or offered for Sale (Section 7044, Business ' and Profeaelons Code) , - CONSTRUCTION LENDING AGENCY - 1 hereby effrrm that there is a construction lending agency for the performance of the work for which this permit IS saved (Sec 3097, - Civ C) Lander a Name Lander a Address 1 certify that I have read this application and state that the above , I Information Is ea I agree to comply with all County ordinances and State la repo laHng Plumbing and hereby authorize - npreaentetive of thle County to enter upon ih above entloned 1,51y f In on purpoeee SEE REVERSE FOR EXPLANATORY LANGUAGE JoL slpneture m Permittee D 7 - WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby, affirm thpt I have a certificate of consent to self in- so-Doze DPW 4/90 ssuurrree�,,oorr�a cernficci Workers'Compensation Insurance,or a 76rke7A opy thereof(Sec 3800 Lob C ) P No �T�„4,�/q�.G COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Au ❑ Certrfied copy is hereby furnished Certified co m filed with the coup building in FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING COPY H 9 spacnon d meet NUMBER FIXTURE OR ITEM ® FTE ADDRESSLOCALITY to f �^Pl6 Date V1 Applicant WATER CLOSET(TOILET) NEAREST - CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST g05<4A4D01JfS COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed If the work involved by the permlt Is for one hundred dollars ({100)or less ) LAVATORY MAIL MAIL5 `tea I certify that in the performance of the work for which this per- mit is issued I shall not employ any penton In any manner so SINK CITY7ET No b as to become subject to the Workers'Compensation Laws DISHWASHER 4SrCONTRACTOR Date Applicant CLOTHES WASHER �cr NOTICE TO APPLICANT If after making this Certificate of Ex- SWIMMING POOL RECEPTOR ADDRESS `L ''.✓/� T emption you should become subject to the Workers Coni sa �, � TEL NO tron provisions of the Lobo•Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok STATE ��yy��jj LIC ed WATER HEATER LICENSE NO "45537 CLASS C Z LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY _ II hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS L-'D,( (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER ✓ c� and Professions Code, and my license is in full force and ef- ' 5 PER SYSTEM FINAL VALIDATION Lice � ..�� s.s�s HOSE BIB DATE License Number �3�isg� Uc Class�(t2 d ,�ss//��r,�,�� FINAL V ContrxtoAkni`!z t.**mSC6�IFiT,.te BY AZTat C 1 am exempt under Sec =�� 1,7�i 0 B dP C for this reason W Plan check fee ► ITEM:, d Signature Date PLUMBING PERMIT ISSUING FEE f TOTAL 72 _75, SINGLE FAMILY TOTAL FEE i 72,7aI HOME OWNER-BUILDER DECLARATION Plan check applicant i ,Qlj I hereby affirm that I am exempt from the Controctor's License Name Low for the following reason (Section 7031 5 Business aril - Professions Code) Address E] I as owner of the property, Qil��—[I�1 5�1✓44 pr o of will do the work and the CSN Tel No r•, structure n not intended or offered for sole(Section 7064 J l�i L F� �'lE 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 ) 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 oil Courtly ordinances and State lowsuqguloting Plumbing and hereby authorize repro es of this County to enter upon the abov -me prop f r inspection pur es ' 14 SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permin Doi.