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Home My Public Portal About9240 WEDGEWOOD ST_Plumbing__ ' WORKER'S COMPENSATION DECLARATION . 20-0026 DPW 9189 1 I 7BA687A APPLICATION FOR PLUMBING PERMIT ll 'I ry9feby'pffirm'that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance,or a certified COPY tvereof(Sec.3800 Lab.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company i Certified copy is hereby furnished. > FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS UILDING 6) qG 0Je V0�W,❑ Certified copy is filed with the county building Inspection department. NUMBER FIXTURE OR ITEM ® FEE LOCALITY Date Applicant WATER CLOSETSS CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work Involved by the SHOWER MAP BOOK �a 6 PAGE 007 1 PARCEL permit is for one hundred dollars($100)or less.) OWNERG'r/r� �+- I certify that in the performance of the work for which this permit LAVATORY Is issued, I shall not employ any person in any manner so as to, SINK J MAIL Y1191M� become subject to the Workers'Compensation Laws. / ADDRESS LL f DISWASHER 0 CITY TEL.NO. Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If; after making this Certificate of CONTRACTOR Exemption,you should become subject to.the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS provisions of the Labor Code,you must forthwith comply with such 11 provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER i 7-1STATE LIC. ILb (commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. CLASS 0 Professions Code,and my license is in full force and effect. OUTLETS OVER •DISTRICT NO. PROCESSED BY � 6 PER SYSTEM pr � Y License Number Lic,Class a G FINAL,07 DATE �` VALIDATION � Contractor Date cc ❑ I am exempt under Sec. FINAL Z B.BP.C.for this reason' Plan check fee of — Date: PLUMBING PERMIT ISSUING FEE$ Signature ❑ TOTAL FEE Plan check applicant SINGLE FAMILY •! HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law ASC E a JTL for the following reason(Section 7031.5, Business and Professions Address -, Code): 36137 City Tel.No. ., I,as owner of the property,will do the work and the structure 1 ITEIS is not Intended or offered for sale(Section 7044, Business. TOTAL® and Professions Code. 43 .00 CONSTRUCTION LENDING AGENCY CHECK T o '1 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097, (::HANE .013 Civ.C.) Lender's Name 0000—CIL-ICII 10/2E27/911 Lender's Address 3433 1 AM f U`_1 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 authorize representatives of this County to enter upon the above-mentioned property for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 44-4� & � WORKERS'COMPENSATION DECLARATION AIl'"PPICATI®N FOR PLUMBING PERMIT I hereby affirm that I have a certifictite of consent to self 76A667A insure, or a certificate of Workers'Compensation Insurance, I CE 817(REV. 10/81) or a certified co thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES f BUILDING AND SAFETY Policy No.o.gd��_Coompan,; ❑ Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 2 � Certified copy is filed with the county building inspec- cin CIS, tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY I DateLA—CL—Q� Appli4an � t`D�� I i WATER CLOSET NEAREST lt , CERTIFICATE OF EXEMPTION FROM WORKERS' I Q BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER _ (This section need not be completed If the work involves by MAIL the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this , permit is issued, I shall not employ any person in any manner SINK CI _ % TEL. -72so as to become subject to the Workers Compensation Laws. ; DISHWASHER CONTRACTOR r I� Date Applicant I CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If; after making this Certificate of G�V _Z Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR , CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions. or this permit shall be STATE LIC: deemed revoked. WATER HEATER LICENSE NO. CLASS, LICENSED CONTRACTORS DECLARATION DISTRICT NO. P ESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS Jr- Q' (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER Q � and Professions Code,and my license is in full force and effect. I 5 PER SYSTEM FINALC74/ VALIDATION License Number:S2A__C;g Sq Lic. Class %.—k ; DATEr U ;! FINAL Contractor DateBY U ❑ ue I am exempt under Sec. C- 0 B.BP.C. for this reason ;i Plan check fee PLUMBING PERMIT ISSUING FEE$ Signature - — - TOTAL FEE �rO Plan check applicant SINGLE FAMILY i HOMEOWNER-BUILDER DECLARATION Name I.hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and, Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the r.0 3 q 5 A structure is not intended or offered for sale (Section 7044, Business and Professions Code). $ c o 0 0 0 5 CONSTRUCTION LENDING AGENCY ^'u '0 2 a 5 Q I hereby off irm that there is a construction lending agency for the performance of the work for which this permit is issued �,o'0 2 5 r Q czi (Sec.3097, Civ. C.). i ' 1 V-84 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 authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _ LA-q-4th" Signature o er.mNei Date 0.6.8.17 SsM SETS$-47 •. • APPBdK.'413S310i`i FOR.Pd'ditiWlSCT PEP RTME+NT OF BUILDING AND -SAFETY COVIfHBg.m OF LOS ANGELES .. .J.FOX.CHIEF ENGINEER Aram ►� LgT� G OIJP PERM ROUGH FIXTURES COMPLETE RECEIVED BY READ FOR' DAIN ISSU HEATER CESSPOOL 8EPTIG TANK FIRST INSPECTI N A APPLICANT FILL IN HEAVILY OI]TLINE0 PORTION ONLY / FOB NAME _.,...�� ".ADDRESS , r M ADDRESS LOCALITY' jNEAREST 0. CITY TEL.'NO. CROSSST. i CO T.NO. EXPIIZEB mss '• .. NAME. LOCATION OF SEPTIC TANS,.OR CESSPOOLaoocd� I AM THE LEGAL PO48B9SOR OF THE ABOVE LOS ANGELES COUNTY CERTIFICATE OF QUALIFICATION. PLumoot I AM THE LEGAL OWNER'OF THU-gROPERTY DESCRf 3KD ABOVE. �S t � tf. d ow1iER� CORRECTIONS • Gr•f. w dm V if ,. -5t plo� SOUTH -1 Q DESCRIPTION OF WORK z BATH TUS --4--FURNACE 19 +•_ HOWER DISHWASHER 3 AVATORY —/--REFRIGERATOR - t ITCHEN SINK WATER SOFTENER FLOOR SINK SAND TRAP P SINK. FLOOR DRAIN - WASH TRAY URINAL APPROVALS J* WATER CLOSET - DR;NK1NG FOUNTAIN DATE m"specrows"Ms "WATER HEATER - DZNrALLAVATORY ROUGH PLUMBING SODA FOUNTAIN GAS PIPING TIL GAS VENT CESSPOOL t TOTAL»NUMBER OF FIXTURES .. SEPTIC TANK 1 ESBPOOI SEP?lCfiANKSEWER Ser UTILITY CO.NOTIFIED TOTAL FE>~, " D.9.8.-17 255 SETS.12-4p APPLICATION FOR PERMIT 'D-EPIRTMENT OF BUILDING AND SAFETY .y COUNTY OF LOS ANGELESLU B' Wm.J. FOX.CHIEF ENGINEER .NATURE OF INSTALLATION DIST ICT NO. GROUP ZONE. PERMIT NO. ROUGH FIXTURES COMPLETE, (+a °F A HEATER __CESSPOOL —I SEPTIC TANK R IVED BY READY FOR DATE ISSUED FIRST INSPECTION L SAS M16CELLAME000 ✓ v-1✓ I O~ I APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY JOB B NAME ADDRESS B ADDR a Z :., LOCALITY D t NEAREST e / CITY & TEL.No. CROSS.ST. P�erl1'GrrQ COUNTY' CERT.No. EXPIRES NAME LOCATION OF,SEPTIC TANK, OR CESSPOOL Z MAIL 3 ADDRESS NORTH O CITY TEL.No. IAM THE LEGAL POSSESSOR OF THE ABOVE LOS ANGELE8 COUNTY CERTIP14FATE OF QU fZIF CATION. PLUMBER. 1 AM THE LEGALOW R OF THE PROPERTY DESCRIBED ABOVE. OWNER • CORRECTIONS SOUTH DESCRIPTION OF WORK a ATN TUB FURNACE ROWER DISHWASHER 0 I/ATORY REFRIGERATOR KITCHEN SINK WATER SOFTENER w^OR SINK RAND.TRAP LOP SINK FLOOR DRAIN WASH TRAY URINAL APPROVALS WATER CLOSETDRINKING FOUNTAIN DATE INSPECTOR'S NAME WATER HEATER DENTAL LAVATORY ROUGH PLUMBING ■"ETER GAS CODA FOUNTAIN OUTL GAS PIPING GAB VENT CESSPOOL lb0 %-`� 10!/-'>S TOTAL NUMBER OF FIXTURES SEPTIC TANK I ESSPOOL____SEPTIC TANK '� SEWER I 1 8 UTILITY CO.NOTIFIED TOTAL FEE I t FINAL