HomeMy Public PortalAbout5430 ENCINITA AVE_Plumbing__ _ WORKERS'COMPENSATION DECLARATION ����I�gTI®� FOR �LUi1fl�l��'s .Q'�Rii�IT
'n Nereby; affirm that I hove a certificate of consent to self ia- ,76A��A PW a(87 n
sunsI a certificate-of Workers'Compensation Insurance,or a CE 817(REV. 8/86) ,ILJI
cf'r they of (Sec. 3800, Lob. C.) -
' � -E2G'I.y�A COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS.
- Policy o.- Company _ •�. 11�. ,cul. •'
Certified copy:is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING2_ Y• a/u11� /
edified copy'is filed with the county building inspection - ADDRESS .7c/ L-F2 .47
NUMBER -FIXTURE OR ITEM FEE LOCALITY
department. @
WATER CLOSET (TOILET) _
DateApplica nt - NEAREST t
CERTIFICATE OF EXEMPTION F OM WORKERS' -
BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER T"
(This section need not be completed if the work involved byMAIL ,cn
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS rlekb (c Ws�L e
I certify that in the performance of the work for which this per- '
mit is issued,.l shall not employ any person in any manner so SINK d CITY. �, .� TEL NO.
as to become subject'to the Workers Compensation Lows. DISHWASHER
CONTRACTOR v—i G bC�+�tj
Date a Applicant CLOTHES WASHER ADDRESS C.'1-Lrh.r -
NOTICE TO APPLICANT: If, after making.this Certificate of Ex- SWIMMING POOL RECEPTOR 1
emption;,you should become subjeci to the Workers'Comport- CITY TEL N0.-
l,T, .9/.zZGfIZ�
sotion provisions of the Labor Code, you must forthwith comp- - 'LAWN SPRINKLER SYSTEM s TCJ IA+ l fl'
ly with such provisions or this permit shall be deemed revok- STATE �''') TIC. n
ed. -'• ' WATER HEATER �1 LICENSE No. (�� 'CLASS
LICENSED CONTRACTORS DECLARATION (l - DISTRICT NO. ROCESSED BY
I'hereby affirm that I am licensed under provisions of 6opter `GAS SYSIEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business - OUTLETS OVER -
fact.Professions Code, and my license is iri,full force and ef- 5 PER SYSTEM FINAL !� /\' VALIDATION
.a
/_j(,, /} ( �j V
LicenseNJ bet.=/ ZZ�Lic Class L- � DATE o
fanbac_tor n Date BY_ BY g r O
I am exempt under Sec.
CL
B.BP.C. for.thid reason Plan check fee _ D i
Dater PLUMBING PERMIT ISSUING FEE$ 50
- - -
Signature I TOTAL FEE -•-- -'
SINGLE FAMILY .
HOME OWNER-BUILDER DECLARATION - Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Nome +• At•C.T.v
Law for the following reason(Section 7031.5, Business and Cr'
Pro94.
Professions Code): Address 3307. 50
OI, as owner of the property, will do the work and the City Tel. No. 1 ITEMS
structure is not intended or offered for sale(Section 7044, C
Business and Professions Code). TOTAL T A =°O
r
CONSTRUCTION LENDING AGENCY '•' - D 'CHEM 94°50
��L����� .00
hereby affirm that there is a construction lending agency for Vntgp,r
' the performance of the work.for which this permit is issued -
(Sec. 3097, Civ. C.).
'Lender's Name 0000-W01 9/14/89
5699 .1 AM10:10
Lender's Address, - -
I certify that I'hove reod this application and state that the
above.information is correct. I agree to comply with all County - D
ordmonces'and State laws regulating Plumbing, and hereby ,
out rize representatives of this County to enter upon the
ave
mentioned pro ty for inspection,purposes.'
t^,lul( / r SEEREVERSE FOR'EXPLANATORY LANGUAGE
S)gnatulre�of PermineeDate +
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