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Home My Public Portal About4919 WILLMONTE AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION a APPLICATO N FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers'Compensation Insurance, E 817(REV. 10/81) or a certified cop thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. mpany6 / BJ� Cert!749WPY s by furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS ertified copy is filed With the county building inspec-• tion department. r NUMBER FIXTURE OR ITEM Q FEE �— _ LOCALITY , Dat/0 7.8 Appligant WATER CLOSET . NEAREST , CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER (This section need not be completed if the work involved by SHOWER the permit is for one hundred dollars($100)or less.) LAVATORY MAIL ADDRESS ) ( ( I �bol�l� i I certify that in the performance of the work for which this � n � permit is issued, I shall not employ any person in any manner SINK CITY t TEL.NO. so as to become subject to the Workers'Compensation Laws. DISHWASHERr / CONTRACTOR1 Date Applicant CLOTHES.WASHER ADDRESS ' NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- CITYANA-fttmTEL.NO. LAWN SPRINKLER SYSTEM �'� with,comply with such provisions or this .permit shall be STATE ��/ LIC. ry� deemed revoked: WATER.HEATER LICENSE NO. — 3�/7� CLASS !7 LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ('commencing with Section 7000) of Division 3 of the BtJsinessOUTLETS OVER. and Professions Code,and my license is in full force effect. ! 5 PER SYSTEM f � DATEL �^ � � VALIDATION V License Number ��27 1 Lic. Class ContracAr -990Kr f Date -14 I am exempt under Sec. ®7 B,&P.C. for this reason Plan check fee Date: ' PLUMBING PERMIT ISSUING FEE$ Signature 6 3 q 4 A TOTAL FEE y SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address I ° ° 0 r t; Law for the following reason (Section 7031.5, Business and Cit ❑ Professions Code): ' Q Jr r x) I y Tel. No. o � o ,• �; I, as owner of the property, will do the work and the 27 , structure is not intended or offered for sale (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for i the performance of the work for which this permit is issued i (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 Cou y to enter upon the above- etntipZnedr ml or in n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date ION WORKER'S I have a certificate of consent to 20-0020 DPw9/88 APPLICATION FOR PLUMBING PERMIT ll I hereby aff6Tm that I have a certificate of consent to self Insure, I , or a certificate of Worker's Compensation Insurance, or a certified I copy th;ersof(Sec.3800 Lab.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS I DEPT.OF PUBLIC WORKS DIV. policy No. Company j Certified copy is hereby furnished. �/ El Certified FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING / G/ ADDRESS (�f Certlfled copy is filed with the county building inspection , department. NUMBER FIXTURE OR ITEM ® FEE LOCALITY Date Applicant _ WATER CLOSET /d—L'fVNEAREST h CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. COMPENSATION INSURANCE BATH TUB ASSESSOR l (This section need not be completed If the work Involved by the SHOWER MAP BOOK PAGB� PARCE�f✓ permit is for one hundred dollars($100)or less.) OWNER I certify that in the performance of the work for which this permit I LAVATORY is Issued, I shall not employ any person in any manner so as to SINK ADDRESS become subject to the Workers'Compensation Laws. � . lk e�o DISWASHER C �� TEL.NO. _ Dat Applicant C CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS provisions of the Labor Code,you must forthwith comply with such 3�' provisions or this permit shall be deemed revoked., LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY /%fi e 7t EL.N -1�y a I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. 410'.? CLCASS LT I , q Professions Code,and my license Is in full force and effect. �( � `� ' 5 PER SYSTEM DISTRICT NO. PROCESSED BY a License Numbed✓A 04�i Lic.Class `'� ~ W DATE O� , FINAL �- VALIDATION a v.- Contractor : ^Z s A j C3"-a 4 Date FINAL // , cc cc ❑ I am exempt under Sec. By 1+ 'A0 B.&P.C.for this reason Plan'check fee Signatt 2 -PLUMBING PERMIT ISSUING FEE$ ❑ TOTAL FEE a s e ti Plan check applicant SINGLE FAMILY ACCTA HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law 3307 70°65 for the following reason-(Section 7031.5, Business and Professions Address Code): 1 ITEMS EJ 1, • Tel.No. I,as owner of the property,will do the work and the structure TOTAL 70.65 is not Intended or offered for sale(Section 7044, Business and Professions Code). , CHECK 70.65 CONSTRUCTION LENDING AGENCY - ; CHANGE °00 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.) i 110110-0001 2/17/93 Lender's Name ° 1 V�40 i Ah111°1r 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 Signature of Permittee r Date 76A6E!-CE817 8.59 - - APPLICATION FOR PLUMBING PERMIT � COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DMSION BUILDING _ JOHN A:LAMBIE,Count y leer CASSATr D. GRIFFIN', Supt of Building LOCALITY _ FOR APPLICANT TO FILL IN NEAREST CROSS ST. r NUMBER FIXTURE OR ITEM OWNERO WATER CLOSET KAM / BATH TUB ADDRESS CITY TEL NO. SHOWER LAVATORY CONTRACTOR rr sn� ADDRESS Tri i'i ;1�1 �i'Il�Rrnl�li ➢�� lrrl &'9C�i>SCJG DISHWASHER CITY L'Anw-(MO.AV& CONTRACTOR'S l..S W..g: 11b�4: "—.• STATE LAUNDRY TUB REGISTRATION NO. /r,O COUNTY / CLOTHES WASHERDISTRICT N 1. GROI9P ZONEPRO ED BY WATER HEATER �� A —/r GAS SYSTEM ' INDUSTRIAL WASTEAPPROVAL IINSPECTION RECORD OR FPER rm 10 D[TURE $ Q DCI AfBMOVALS DATE C INSP OR'S SIGNATURE PERMIT $ 2 00 UNDER WORK ` t TOTAL FEEROUGH PLUMBING 7' a: ,--e - GAS PIPING - I HEREBY ACKNOWLEDGE THAT 1 HAVE. READ THIS APPLICATION 3^�E o AND STATE THAT THE ABOVE IS CORRECT' AND AGREE TO COMPLY GAS VENT WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING . PLUMBING. HOT WATER HEATER I HEREBY CERTIFY THAT 'I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES LICENSED' AS REQUIRED BY LOS ANGELES COUNTY AND STATE. OF GAS TEST CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE - DESCRIBED RESIDENTIAL PROPERTY. UTILITY CO.NOTIFIED SIGNATURE OF PERMITTE .Q� FINAL ®e VAIMATION ROBERT A.WOOD, cs. M.o. casR SUPERVI8ING IIQECHANICAL ENG'Ii 9IS., 4 1 4 U DEC 2 5' A 12-00 M