HomeMy Public PortalAbout5341 ENCINITA AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to sPff 76&6'7A, '
insure, or a certificate of Workers' Compensation Insurance, - C€817(REV. 10%81)
or a�ifi�cicopy ther/of�S�ec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.—Company— WAUJ, t-,
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
ADDRESS
Certified copy is filed with the county building inspec-
tion depaarttment. NUMBER FIXTURE OR ITEM FEE LOCALITY 15
Date v Applicant I WATER CLOSET b y oO NEAREST
CERTIFICATE OF EXEMPTION OM WORKERS' BATH TUB ® CROSS ST. r �j
COMPENSATION IN RANCE SHOWER D O OWNER GU %NC
(This section need not be complete if the work involved by MAIL .�
the permit is for one hundred dollars ($100)or less.) LAVATORY ®� ADDRESS J, :EttA/ is✓/
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK ® CITY !; PLC_ TEL. NO.
so as to become subject to the Workers Compensation Laws. DISHWASHER �r
00 CONTRACTOR 60,g
DateApplicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY qJqq0 TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM �'� _/�
with comply with such provisions or this permit shall be STATE YI C�v CLASS G3 l(J
deemed revoked. WATER HEATER OD.LICENSE NO. J
LICENSED CONTRACTORS DECLARATIONDISTRICT NO. P CESSED•BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS c >
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER }
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL
//���] DATE VALIDATION 0
License Numbery� /���� Lic. Class (a_--ab �
t
FINAL
Contractor Date ' BY
�A
❑ I amF. for
pt under Sec.
B.&Pthis reason
Plan check fee 00.
Date: PLUMBING PERMIT ISSUING FEE$ ® ('
Signature
TOTAL FEE lbo
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I 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 r. T
structure is not intended or offered for sale (Section ® _'� f{r-
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 pro ty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Cxy
Sign re of Permittee Date