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Home My Public Portal About5446 WELLAND AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I heregy affirm that I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers'Compensation Insurance, 76AS67A or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS A19GELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. BUILDING i/r ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS �4q t AVE E Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM tion department. @ FEE LOCALITY •E Date Appligant WATER CLOSET NEAREST {{�� r CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 1 CROSS S7. !t)N 7 A COMPENSATION INSURANCE ` OWNER � L (This section need not be completed If the work Involved by SHOWER the permit is for one hundred dollars($100)or less.) LAVATORY MAIL ADDRESS �qhFIe I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner SINK CITY ka 5,,E M I-A I TEL. so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRI PROLE Y I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS o (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER (((333 and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL V LIDA License Number Lic. Class TI DATE O 1. V FINAL Contractor Date BY I a ❑ I am exempt under Sec. LU B.BP.C. for this reason Plan check fee ® U3 Date: PLUMBING PERMIT ISSUING FEE$ Signature I TOTAL FEE \J Plan check applicant } SINGLE FAMILY h HOME OWNER-BUILDER DECLARATION Name' f�t.1�To4 I hereby affirm that I am exempt from the Contractor's License Address :`+,�� 35.5-J Law for the following reason (Section 7031.5, Business and -.••=+ fessions Code): City Tel. No. i 1TCI':2: I, as owner of the property, will do the work and the r 131 structure is not intended or offered for sale (Section —c n •-y 7044, Business and Professions Code). ,L•- ,� i t,.•1+��+5 3-o 511 CONSTRUCTION LENDING AGENCY r•j;rr r^- ' I hereby affirm that there is a construction lending agency for t.nKN-i-C o� the performance of the work for which this permit is issued ' (Sec. 3097, Civ. C.). 15-10C 1_0 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 reprelentatives of this County to enter upon the above-mt ed;7,411111? ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE L� b Signature of Perniffiee Date WORKERS'COMPENSATION DECLARATION I APPLICATION FOR PLUAhBING PERMIT I hereby affirm that I have a certificate of consent to self 76Aby7A insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof(Sec. 3800, Lob. C.) I COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) A ILDIN ' y�j Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM (t� FEE tion department. WATER CLOSET A,, LOCALITY ' Date Appli4ant. EAREST• CERTIFICATE OF EXEMPTION.FROM WORKERS' BATHTUB OSS ST, l/y riS OW COMPENSATION INSURANCE !/��L�C'C� :� fk. SSS/ (This section need not be completed if the work involved by MAIL SHOWER NER��' the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of.the work for which this permit is issued,I shall not employ any person in any manner SINK. CIN TEL.NO.,�j�jp so as to become subject to the Workers'Compensoti n Laws: E/� L �i�` Q DISHWASHER CONTRACTOR Date ? ' v�Applicant CLOTHES WASHER J' ADDRESS NOTICE. TO APPLICANT: If, after making this Certificate of SW Exemption, you should become subject to tLAWN SPRINKLER SYSTEM he Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY TEL.NO. with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS. LICENSED CONTRACTORS DECLARATION DISTRICT NO . P CES$ED BY I hereby affirm.that I am licensed under provisions.of Chapter 9 GAS SYSTEM OUTLETS f (commencing with Section 70Q0.)of Division 3 of the BusinessOUTLETS OVER and Professions Code,and m license is in full force and effect. 5 PER SYSTEM y FINAL', VALIDATION � License Number 'Lic:Class DATE 0 - FINAL' C9 Contractor Date I BY ❑ I am exempt under Sec. LU B.BP.C. for this reason 1 Plan check fee ► Date. PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Iry j 'SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am.exempt from the Contractor's License 11 Address LOW for the following reason (Section 7031.'5, .Business and '5v8 ( A Profe Bions Code): I City Tel. No. A, 1, as owner of the property, will do the work and the j �; 0 0 0 o n structure is not intended or offered for sale (Section 1 , 7044, Business and Professions Code). ,° ° 2850 CONSTRUCTION LENDING AGENCY o r o 2 0 cT: I hereby affirm that there is a construction lending agency for the performance of,the work for which this permit is issued n 7 —F (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 laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes.JC p� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date