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Home My Public Portal About10906 WILDFLOWER RD_Plumbing__ WORKERS'COMPENSATION DECLARATION A A P P L I C A T 1®N F O R -P L U M B I N G P E R MI.I T I hereby affirm that I have a' certificate of conse�tt tro self � cc ce a,ear(z-eo) insure,or a certificate of Workers'Compensation Insurance,or A certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY ; Policy No. Company, Certified copy is hereby furnished. 1 FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING r I, r r 1 ly 9ADDRESS ' Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM ® F j department. LOCALITY r. •nr} ;j 4 WATER CLOSET M Date Applicant - .NEAREST r -BATH TUB ROSS ST. P..i 1: 0 CERTIFICATE OF EXEMPTION FROM WORKERS' ` } {�COMPENSATION INSURANCE I SHOWER OWNER /4 COMPENSATION r+t O LAVATORY MAIL r �r!` r i • r " / r iii i '� U (This section need not be completed U .the work involved 4., ':• . bg the'.permit j's for one hundred.dollars ($100)' oi;less.)' ,r ADDRESS' r SINK �' -CITY �� s ti# TEL.�NO. �".;.:r rr' r J I'I iffy that in the.,performance of the work for which this DISHWASHER' LL permit is issued, I•shall not employ any person in any-manner CONTRACTOR } 'so as to become subject to the Workers'Compensation';Laws. CLOTHES WASHERcc ADDRESS Q Date Applicant SWIMMING POOL RECEPTOR CITY TEL.NO..ABY a NOTICE TO AP.PLICANT:•If, after'ina..king this Certificate of O Exemption•, :you should become subject to the ,Workers' LAWN SPRINKLER SYSTEM CL STATE LIC. Compensation provisions of the Labor Code, you must,forth- 04th comply with such provisions or this. permit shall be WATER HEATER LICEN$E:NO.. CLASS � deemed revoked. DISTRICT NO.. ,P CES GAS SYSTEM OUTLETS • LICENSED CONTRACTORS DECLARATION OUTLETS OVER I herebyaffirm that I a licensed lY 5 PER SYSTEM m is nsed under provisions of C apter 9 (commencing•.with Section 70.00)of Division 3 of:the'Busi- rFN L s� VALIDATION ness and Professions Code, and.my license is in full force and ',if•r �� effect. '. d L License Number: Lic.Class Contractor Date I am exempt from the licensing,requirements.as I�am a Plan check fee licensed architect or a registered professional engineer + / acting in my professional capacity (Section,70SI,•Bus- PLUMBING PERMIT ISSUING FEE$ ./4L iness and Professions Code). t TOTAL FEE �� ✓ . Lic:or Reg.No. Date Plan check applicant n HOME OWNER-BUILDER DECLARATION Name J �t V hereby affirm that I am exempt from.the Contractor's Address License Law for the following-reason (Section.7031.5, oili- City Tel.No; nese and Professions Code): - ' r to � •Y, El 1, as owner of the property,-am.exclusively contracting �; °•�rt • ,y with licensed contractors'to'construct •the project ., ' (Section 7044,Business and Professions-Code). ,Q.� � �!t •�i� , CONSTRUCTION LENDING AGENCY _ I'.liereby 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 all Cdunty SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby _ authorize representatives of this County to.enter upon the above-mentionedproperty for inspection purposes. Signature of Dbrmittee Date WORKERS'COMPENSATION DECLARATION 76A667A I hereby affirm that I have a certificate of consent to self ce 617 (2-60) APPLICATION F O R P L U M B I N G PERMIT insure, or a certificate-9f Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) �� 'r7n� COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ADDRESS Certified copy is filed with the county building inspection iNUMBER FIXTURE OR ITEM FEE - dei ar ment. I LOCALITY Date .1212fimApplicant AAA c-ona. 4r�, '��_ WATER CLOSET NEAREST BATH TUB CROSS ST. IL CERTIFICATE OF EXEMPTION FROM WORKERS' SHOWER OWNER Qj COMPENSATION INSURANCE LAVATORY MAIIL LU(This section need not'be completed if the work involved ADDRESS ..I by the permit is for one hundred dollars ($100) or less.) 219906 SINK CITY -TEL.NO. L -MIR 19 a-eity I certify that in the performance of the work for which this DISHWASHER CONTRAC OR IX is issued, I shall not employ.any person in any manner so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER ° Q ADDRESS Date Applicant SWIMMING POOL RECEPTOR a per. NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO. Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM 07 grAilte STAT9 LIC. -1190 US Compensation provisions .of the Labor Code,you must forth- ;. WATER HEATER' LICENSE-NO. CLASS, with comply with such provisions or this permit shall be deemed revoked. &f, DISTRfC GAS SYSTEM OUTLETS N0.� PROCESSED BY - s / LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000)of Division 3 of the Busi- FINAL ness and Professions Code, and my license is in full force and DATE VALIDATION effect. FINAL License Number 293529 Lic.Class C20 BY Contractor 'Aw COnd- Al-Date 12016/8$ I am exempt from the licensing requirements as I am a' Plan check fee �) licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE Lic.or Reg.No. Date Plan check applicant 11% . HOME OW,NER-BUILDER DECLARATION Name • �la,o o•'a a Address I hereby affirm that 1 am exempt from the Contractor's �.:! License Law for the following reason (Section. ° , T �+ g ( City Tel.No. , t ness and Professions Code): OI, as owner of the property, am exclusively contracting �►T with licensed contractors• to construct the project (Section 7044,Business and Professions.Code). �'t"' •�'- `' CONSTRUCTION LENDING AGENCY' I hereby affirm that there is's construction lending agency for the performance-of the work for which this permit is i 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 all County SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. Signature of Permittee Date = ;e 8R APPLICATION FOR PLUMBING PERMIT 1 BUIEDING AND SAFETY DIVISION Department of County Engineer County of Los Angeles BUILDING D JOHN A.LAMBIE,COUNTY ENGINEER ADDRESS CASSATT D.GRIFFIN,,SUPT OF BUILDING - LOCALITY FOR APPLICANT TO FILL IN NEAREST CROSS ST. OWNER DISTRICT NO. GROUP ZONE READY FOR INSPECTION MAIL �� r ADDRESS e� 1A. INDUSTRIAL CITY TEL.NO. WASTE.APPROVAL PLUMBER INSPECTION RECORD ADDRESS - Z!/• ias CITY JJe— TEL.NO.e94 3 LICENSE NO. /lvp �1 7 -NUMBER TYPE OF FIXTURE OR ITEM FEE WATER CLOSET (TOILET) @ $1.00 $ 1 �► BATH TUB Q $1.00 SHOWER @ $1.00 LAVATORY (WASH BASIN) @ $1.00. Af KITCHEN SINK Q $1.00 DISHWASHER @ $1.00 LAUNDRY TUB OR TRAY @ $1..00 CLOTHES WASHER @ $1.00 WATER HEATER @ $1.00 GAS SYSTEM @ $1.00 F APPROVALS DATE INSPECTOR'S SIGNATURE UNDER SLAB WORK / R ' OUGH PLUMBING R"-' +I f i + [�: PERMIT $ I 00 � ff GAS PIPING r 1�' r6 i /.d.'t'ti✓% TOTAL FEE. GAS VENT I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION D .,•HOTW�ITER HEATER r�D ANSTATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING '` PLUMBING FIXTURES -j-D )r s•�` PLUMBING. I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR GAS TEST +�/7 I LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE UTILITY CO.NOTIFIED DESCRIBED RESIDENTIAL PROPERTY. a SIGNATUR3. E L OF PERMITTEE FINAL e> vet. +a.Iv/ ROBERT A.WOOD. JOHN A.LAMBIE.COUNTY ENGINEER ALEDATION SUPERVISING MECHANICAL ENG'R �K. SO4 ON.; OCT 1 $ 3 $.a 0 M F •