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HomeMy Public PortalAbout5347 ENCINITA AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION "' APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate,of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, . CE 817(REV. 10/81) or a certifiedc py thereof Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES / l BUILDING AND SAFETY �d -vLa-051999 L��4uS� Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �B Y G , `'� Certified copy is filed with the county building inspec- ADDRESS a V ti�o(n department. NUMBER FIXTURE OR ITEM @ FEE{ LOCALITY rkm Date 8-3 4 Applicant � WATER CLOSET U) n0 NEAREST 7 CERTIFICATE OF EXEMPTIO ROM WORKERS' t BATH TUB �© CROSS ST. COMPENSATION )J URANCE SHOWERO i OWNER Ly r (This section need not be completed if the work involved by V MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY Oo ADDRESS 908& r, S LLAT I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner I SINK ID100 CITYn6al ALE C TEL. NO. r q 6g so as to become subject to the Workers Compensation Laws. DISHWASHER oo CONTRACTOR Wd m 1Aj6 Al! Date A licant CLOTHES WASHER O t NOTICE TO APPLICANT:pf, after making this Certificate of ADDRESS �� �.da1C� 00d � Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM AID/?g 0 O 5 with comply with such provisions or this permit shall be STATELIC. deemed revoked. WATER HEATER to LICENSE NO. 3 oo CLASS L3 LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCESSED B.Y GAS SYSTEM OUTLETS I hereby affirm that I am licensed under provisions of Chapter 9 (� � (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and effect. 5 PER SYSTEM e FINAL I. /7 ✓��_ DATE VALIDATION License Number 5 0049 Lic. Class ��`� FIN ate -�� BY AL Contractor 1 ❑ ay I am a pt under Sec. 1 fj B.&P.C. for this reason Plan check fee Date: o PLUMBING PERMIT ISSUING FEE$ oil Signature TOTAL FEE Plan check applicant _ SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address !. r, r Professions Code): City Tel. No. ; 9600 ❑ I, as owner of the property, will do the work and the ® i) C C 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 0 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 -g S' ature of Permittee Date