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Home My Public Portal About9627 WOODRUFF AVE_Plumbing__ �. WORKER'S COMPENSATION DECLARATION 7�67N!'W9f� APPLICATION FOR PLUNKING PERMIT I hereby affirm that I have a certificate of consent to self Insure, or adertificate•ot Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) Policy No. 3510555 Company REPUBLIC MCOUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ..ADDRESS 9627 MODEM AVENUE Certified copy is filed with the unty bull 'n inspection department. NUMBER FIXTURE OR ITEM FEELOCALnY gagU CITY, CA Date Applica �i WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM ORKERS' � BATH TUB CROSS ST. ASSESSOR - COMPENSATION INSURANCE MAP BOOK PAGE PARCEL (This section need not be completed if the work Involved by the SHOWER �� permit Is for one hundred dollars($100)or less.) ILAVATORY D OWNER JEFF .TATATAT I certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to SINK ADDRESS 357 W WAUfff become subject to the Workers'Compensation Laws. DISWASHER n( CITY ARCADIA CA 91006 TELM/447-4824 Date Applicant CLOTHES WASHER �i✓ CONTRACTOR FRANK MARRONE $c SM, INC. NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'CompensationSWIMMING POOL RECEPTOR ADDRESS provisions of the Labor Code,you must forthwith comply with such 9860 MER AZUSA ROAD provisions or this permit shall be deemed revoked. i LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION / CITY EL M WM CA 91731 TEL'rR8/444-2548 >` I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER CL (commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS (� ' CA NSE NO. 397884 TE �LLASS C/36 C/16 Professions Code,and my license is In full force and effect. OUTLETS OVER DISTRICT NO. ROCESSED BY a: 397884 C/36 C/16 5 PER SYSTEM 337 40 License Number Llc.Class I` FINAL VALIDATION � F. MARRONE & SONS INC 12/31/96 DATE .� ISL Contractor ' bate ❑ I am exempt under Sec. BY AL B.&P.C.for this reason ITF15 Plan check fee ® ' 'p Date: Signature PLUMBING PERMIT ISSUING FEE$ ElTOTAL FEE CHANGE ^ SINGLE FAMILY Plan check applicant OWO-0001 9/25/95 HOME OWNER-BUILDER DECLARATION -Name �4T 1 AM11o3 I hereby affirm that I am exempt from the Contractor's License Law f for the following reason(Section 7031.5, Business and Professions Address Code): El 1, Tel.No. I,as owner of the property,will do the work and the'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 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 County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned 48gn�atu action purposes. n �• SEE REVERSE FOR EXPLANATORY LANGUAGE 'UX � Com—",re of Permittee Date WORKERS'COMPENSATION DECLARATION 20-0026 DPW 4/90 APPLICATION FOR PLUMBING PERMIT Y hereby,, affirm that I have a certificate of consent to self in- 76A667A sure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800, Lab. C.) Policy No. 095`0W R6 Company Cot r'•+1'YC COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ❑ Certified copy is hereby furnished. ? FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ADDRESS Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM department. FEE LocLOCALITYWMPL� �1• Dote 3 q (�!1(OApplicant_I A*Y GUIU iVA4 WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.OWNER� JssSf COMPENSATION INSURANCE SHOWER (This section need not be completed If the work involved by MAIL the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS e I certify that in the performance of the work for which this per- SINK CITY TEL.NO. APYt7` 1 mit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTORWay 6wl-ec4o Date• Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of E)i- SWIMMI G OOL RE OR •� emption,you should become subject to the Workers'Compen- CITY sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINK SYSTEMS /0/� ly with such provisions or this permit shall be deemed revok- C7 STATE J` TEL.NO. LIC. - ed. WATER HEATER LICENSE NO. -?12 CLASS Z LICENSED CONTRACTORS DECLARATION DISTRICT NO. c . PROCESSEb BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �� ✓� _� 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER s2i and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL 7 VALIDATION fect. ^ HOSE BIB DATE IL License Number �3(� Lic. Class e�2 FINAL Contractor 2 5 LSA ULaSCA>� Date 3 BY ACCT.%.01 a & oz I am exempt under Sec. /� �0 3303 4 5.40 V B.BP.C. for this reason Plan check fee .1 ITEMS w Date: PLUMBING PERMIT ISSUING FEE$ � ® TOTAL 43.40 z Signature TOTAL FEE i CHECK 43.40 SINGLE FAMILY CHANGE .00 HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and no-0001 3l 4�� Professions Code): Address I, as owner of the property, will do the work and the City Tel. No. 509E 1 AM 9°5.5 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 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 County Poo ordinances an S to laws regulating Plumbing, and hereby authhXi natives of this County to enter upon the q oksov - menti_ e roperty for inspection purpose 3�GI6 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date