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Home My Public Portal About5266 SERENO DR_Plumbing__ WORK ERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 1 F(ereby, affirm shpt I Fiavea certificate of coroent to self m- 76A667 DPW V90 sure,or a certificate of Workers Compensation Insurance,or a 7eA667A �7 Company c copy thereof(Sec 3&10 Lob C ) QUI Po5 cy No-AM-1119W-01 (iJbi 1)Gd.A F�c446,lk COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy nfded with the county building inspection ADDRESS �R- de mens NUMBER FIXTURE OR ITEM 6 FEE LOCCl1TV Data Applicant �.Icl�e7 WATER CLOSET(TOILET) NEAREST RTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS Sr 40 COMPENSATION INSURANCE- SHOWER - OWNER (This section need not be completed if the work Involved b7 MAR the permit is for one hundred dollar($100)or less) LAVATORY - ADDRESS I comfy that, I the performance of the work for which this per- SINK CITY ,�a, _ C �� TEL NO ,/ mit a issued, I shall not employ any person m any manner so Tim 7 1 as to become subject to the Workeri Compensation Laws DISHWASHER CONTRACTOR Date Appjicont CLOTHES WASHER ADDRESS NOTICE TO APPLICANT If, after making this Cemficote of Ex- emption,you should become subject to the WorkerCITY m'Compen- SWIMMING POOL RECEPTOR CTEL NO scion provisions of the Labor Core,you must forthwith comp - LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE NO �33 ss/ LIC ed WATER HEATER 7 � LICENSED CONTRACTORS DECLARATION DISTRICT NO ` EQ BY I hereby offum that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS D�// 9(commencing with Section 7000)of Division 3 of the Business OUTLETS ODER and Professions Code and my license r in full force and ef- S PER SYSTEM FINAL fact HOSE BIB DATE License Numbers Lic Class �' Z I_.-� �� ,(, FINAL TOTAL 103 . 6 vi ConP nacto#At-Vo LASM 1e BYHE�C/Ky 1U3.51C cR ❑ / / CHECK I am exempt under Sec ( I (IV B BP C for this reason Plan check foe ► �E ] d 'Date Signature PLUMBING PERMIT ISSUING FEE f 5/12/Q 1A 5/1J.4 - 0 TOTAL FEE 5190 1 PM 5:17 SINGLE FAMILY HOME OWNER BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor s License Name ` Law for the following reason (Section 7031 5 Business and Professions Code) Address ' ❑ 1, as owner of the property will do the work and the Cay Tel No structure is not intended or offered for sole(Section 7044, ' Business and Professions Code) - ► CONSTRUCTION LENDING AGENCY - I hereby offum that there is a construction lending ogency for the performance of the work for which this permit is issued (Sec 3097 Civ C ) Lenders Nome t Lender s Address I certify that I have reod this application and state that the , above information is corre I agree to comply with all County ordinances and St a gulating Plumbing and hereby authorize rept ntoti this County to enter upon the obov pr r or inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per t e Date .WORKO COMPENSATION DECORATION t010M 46157DPW 9/80e/ APPLICATION FOR PLUMBING PERMIT ll 70 I hereby affirm thattI have have a certificate of consent to Bell Insure or a certllicals of Worker a Compensation Insurance, or a certified I , copy thereof(Sec 3800 Lab C) I - - ` PolicyCOUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS ;� l•DEPT,OF PUBLIC WORKS DIV No —Company ` ❑ cerinbd copy b hereby fumWied , FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ❑ Certified coPY Is Bbd with the county buAdkp inspection ADDRESS dwarurwd NUMBER FIXTURE OR ITEM O FEE LOCALnY Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS ---------BATX ng ( ST 'eR... COMPENSATION INSURANCE MAP BOOK PAGE 199 PARCEL (This section need not be Completed H the work Invotved by the SHOWER - permit Is for one hundred dollars($100)or leu) LAVATORY OWNER '� v I certify that In the performance of the work for which this Permit MAIL is Issued, I shell not employ any person In any manner so as to SINK ADDRESS become 3ybject the Workers Compartzation La DISWASHER CITY NO l Af? APpLicant CLOTHES WASHER NTRA NOTICC TO APPLICANT If offer making this Certificate-15f _ CO CTOR 0-jp v/"61/7 Exemption,you should become subject to the Workers Compenutiun SWIMMING POOL RECEPTOR ADDRESS //� proviamns of the Labor Code you must forthwith comply with suchJOV/ 141 pro,twons or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM 1 LICENSED CONTRACTORS DECLARATION WATER(EATER CRY t L d I hereby affirm that I am licensed under provisions of Chapter 9 o (commencing with Section 7000)of Division 3 of the Business and STATE NO S6 LCC O GAS SYSTEM OUTLETS Professions Code and my license Is In full force and effect U OVER dSTRICT NO Prue' BY IZ 6 PEAR BSSTEM D 0 License Number LIC Claes Fl"uVALIDATION - a DAA O e rn ` El I em exempt under sec , � BVD B$P C for this reason Date Plan check fee , C PLUMBING PERMIT ISSUING FEE$ a Sfprleturs TOTAL FEE Q I F1r Plan check applicant3307 SINGLE FAMILY 1 1TEM HOME OWNER BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor s License Law TOTAL 250 . 6S for the following reason (Section 7031 8 Business and Professions Address - Code) CItY Tel No i t.`�ECK 250.65 ❑ I as owner of the properly will do the work and the structure LTIe'B1� .0(I is not Intended or offered for sale (Section 7044 Business and Professions Cade) CONSTRUCTION LENDING AGENCY 5/12193 1 haraby affirm that there is a construction landing agency for the perlormance of the work for which this permit Is Issued(Sec W97 - 9677 1 ,fes 9:20 Civ C) v Lender a Name Lender a Address I certify,that I have read this application and state that the above Pol.Information Is Correct I agree to comply with all County ordinances and Stale law$ regal ting Plumbing and hereby authorize representatives of this ounty to enter upon the a e m Cloned prope�mpe urposae SEE REVERSE FOR E(PUWATORY LANGUAGE G v /Y 53 Signature of Perr iMere Date