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HomeMy Public PortalAbout5502 WELLAND AVE_Plumbing__ ,i^ .• "WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 4nsureti 0 or a certificate of.Workers'Compensation Insurance, 76AG67A o- ii tified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS Policy 13o. Company ❑ Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING O Z Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM ® FEE LOCALITY �(Iv! ^(`� t I D Date Appli4ant WATER CLOSET DO NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB O CROSS ST. DA-04L DA COMPENSATION INSURANCE SHOWER /�'1 OWNER a( (This section need not be completed If the work involved by V the permit is for one hundred dollars($100)or less.) LAVATORY n /y�l IW►IL I certify that in the performance of the work for which this OC ov ADDRESS U permit is issued,I shall not employ any person in any manner SINK CITY A,�A-M)WX4- TEL. NO.(b)IPS so as to become subject to the Workers'Compensation Laws. DISHWASHER �1 CONTRACTOR IV�/ g U{LP&X Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- LAWN TEL.NO. LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 1-10 (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER ' and Professions Code,and my license is in full force and effect. 5 PER SYSTEM /_D NAL � �© V LIDATION License Number Lic. Class BY FINA/4`0-10 Contractor Date of ❑ I am exempt under Sec. C B.BP.C. for this reason CL Plan check fee Date. PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE SINGLE FAMILY Plan check applicant 0(,& (;ro/V' HOME OWNER-BUILDER DECLARATION Name ACCT.0 I hereby affirm that I am exempt from the Contractor's License Address j y j 6 E-L M C1( � o Low for the following reason (Section 7031.5, Business and I� Professions Code): CitFul 1y Tel. No. �['K - 1 ITEMS I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section Inp— TOTAL + v � 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CASH 46.50 1 hereby affirm that there is a construction lending agency for ��� e the performance of the work for which this permit is issued 00 (Sec. 3097, Civ. C.). Lender's Name 0000--Mol $/ U Lender's Address. 1 M 90.05 1 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 \ Signature �ftrmiilt�� ��of {J s WO�iKER'SCOAAPENSATIONate of consent to 7�67DPW ele9 APPLICATION FOR PLUMBING PERMIT u I hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company ❑ Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING s � Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM ® FEE LOCALITY Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. COMPENSATION INSURANCE BATH TUB ASSESSOR (This section need not be completed If the work Involved by the SHOWER MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) OWNER I certify that in the performance of the work for which this permit LAVATORY Is Issued. I shall not employ any person in any manner so as to SINK MAIL become subject to the Workers'Compensation Laws. ADDRESS _moi DISWASHER CITY TEL.NO. Date Z Applicant lLZJfZU CLOTHES WASHER NOTI TO PPLICANT: If, after m_aking!this Certificate of CONTRACTOR ` p Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR , f provisions of the Labor Code,you must forthwith comply with such ADDRESS vZ provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. ,�3 �O,Y >' I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER a (commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS CESTAT SE NO. CLASS C` 0 Professions Code,and my license is In full force and effect. OUTLETS OVER DISTRICT NO. PROCESSED BY IX 5 PER SYSTEM Q License Number Lic.Class FINAL VALIDATION U.1 77 DATE CL Contractor atefA ❑ I amexempt u der Sec. gy AL B.&P.C.for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signaturegoorvow l� ❑ TOTAL FEE o SINGLE FAMILY Plan check applicant A_t T a v i�. HOM DECLATIO LD I hereby affirm thaE am exemptlfrom the Conttrrac or's License Law Name 3307 r963,0 for the following reason(Section 7031.5, Business and Professions Address ITEMS Code): ❑ I,as owner of the property,will do the work and the structure city: Tel.No. TOTAL 39 o 30 is not intended or offered for sale(Section 7044, Business CHECK (y and Professions Code). CONSTRUCTION LENDING AGENCY CHANGE ,�E: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, Civ.C.) 7 i l J Lender's Name 549? 1 An 10 o c'+ 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 prop tion purpo es. / SEE REVERSE FOR EXPLANATORY LANGUAGE Sign a4u Dat