HomeMy Public PortalAbout4930 ENCINITA AVE_Plumbing__ ° —'-----WORKERS'rC0MPENSA710U.DECtARATION APPLICATION FOR PLUMBING: PERMIT
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rl hereoy affirma that I have a certificate of consent to self 76A667A
btisure, &,o certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) `
or a certife cc/o�pyjit'h�ereof (Sec. 38 b. c.) COUNTY OF LOS ANGELES-
BUILDING AND SAFETY
Pblicy No/o��Campan �
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �A
Certified copy is filed with the county building inspec- ADDRESS !/
tion department. ��/�/ NUMBER FIXTURE OR ITEM @ ' FEE
�`�/ ��G _ LOCALITY
Dat Applicant /�^z/ WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCESHOWER ij� OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY < <j� dd ADDRESS >V f
1 certify that in the performance of the work for which this SINK OQ CITY ` TEL. f�C9
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR 4`
Date Applicant CLOTHES WASHERo
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATELIC.
deemed revoked. WATER HEATER Qp LICENSE NO. l CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO u PRO SS BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER `
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALID? ON
a�/� .0o DATE — 0
License NumbeF—J f Lic. Class /" — Q
B N / U.
Cantrac+� iy� � Date O �'
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I am exempt under Sec. U
B.&P.C. for this reason Plan check fee ► /t C,
3 Cf)
Date,: PLUMBING PERMIT ISSUING FEE$ d o o Z
Signature 0 0 0 QO x
TOTAL FEE 07.0
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): City 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
property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee Date
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