HomeMy Public PortalAbout5434 ENCINITA AVE_Plumbing__ WORKER5;,COMPENSA71ON DECLARATION026DPW a/8] APPLICATBOWFOIR PLUMBING PER
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- ereby affirm thoh,f have'a cer20-0
tificate of consent to self,in- 20-0 A "TILJII
sure,ora certificate of Workers'Compensation Insure ce, or o 'CE 817 (REV. 8/86)
cer.fi <pp thereof (Sec 3800 Lo ) 1
�'' - • COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy o: Company
Certified copy is hereby furnished: .. _
FOR APPLICANT TO FILL IN,(➢RINTOR TYPE) BUILDING
��,/}]=ert tied copy istiled-with the unty building inspection - ADDRESS ✓ V �{j �/�Q
department.^ - NUMBER FIXTURE OR ITEM @., FEE !OCALIT�
+ `� WATER CLOSET (TOILET) _
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM,WORKERS'- •BATHTUB CROSS.ST. �.
COMPENSATION INSURANCE
SHOWER, OWNER 61 .
(This section neednot'be completed if the work involv by ' '.. _ MAIL _ '
thepermit is for one hundred dollars ($100) or less.) - ¢ LAVATORY ADDRESS Q�" Yro
rCfy the Lin Ike performance of the work for which this per-
Lc'en
Per-
m
itis.issued, sm
hall not employ any person in.Ony'mSINK abner so ' - CITY '•TEL'NOL76 t,
'as,to become subject to the Workers' Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant - - - f CLOTHES WASHER
NOTICE TO ARE If, after making this Certificateof Ex- ADDRESS Z
em tion, oushould become subject to the Workers'Com eri- SWIMMING POOL RECEPTOR
P Y P _ CITY 1^ TEL N .
SOtion provisions,oP the,Labor Code; you must forthwith comp- .LAWN'SPRINKPER SYSTEM - = '
ly with such provisions or this.permit shall be deemed revok- .STATE LIG , •
ed•, t . s - . • [� WATER'HEATER LICENSE NO. - , , 111--54
LICENSED CONTRACTORS.DECLARATION a.. - STRICT-NO. PROCESSED BY
I'hereby affirm that l am licensed under provisions of Chapter
GASSYSTEM' OUTLETS
9(commencing`with Section 7000)of Division 3 of;the Business OUTLETS OVER
and Professions Go e,'ond my license 5 PER SYSTEM s in full force and-ef- _ FINAL q �. VALIDATION O
fe^t. �7��•y�,/�} s, (/'�` j7 DATE'
licppe��rr77))� Num6e .�� Gc Classes
�7C (p{[. f.TQ Date=� ,.
-- 'FINAL
U
.Contractor' - BY Q
am exempt under Sec. J/ ` •i' W
B 8P C. mr'th s reason Plan check fee
- -•Dale: . - - PLUMBING PERMIT ISSUING FEE $ in
'' Signature r
+TOTAL FEE' ,.
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION .Plan check opplicant• 5 -
I hereby 6ffirm than am exempt from the Contractor's License Name -
Low for Thefollowing reason (Section 70315; Business and-, _ AC•CTi4`
Professions Code): f: Addres_s"- r 3307 94.50
❑, .I, as owner-of the prbperty, will do the work'and the city Tel. No. - _ 1 ITEMS
structure is not intended or offered for saleSection 7044 _- - AA''
Business and Professions Code)
_ ( TUT11L \:-' '4'm CO .
CONSTRUCTION LENDING AGENCY - CHECK 94.50
I hereby affirm that there is a construction-lending agency for - _ _ CHANGE .011
_The.performance of the work for which this permit is issued 's
(Sec. 3097,.Civ, C.). .. -
Lender s Name 0000-0001 y 9/14/89
5701 1 AM10:11
Lenders Address _ -
I certify;that I,have read this application and state that the D
above information is correct: I agree td comply with all County
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d, races and State laws regulating Plumbing, and'.hereby -
zrepresents ' s of this County to enter upon the ned pr per f 'Te<tion purposes. - ,
_ - �( SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of permittee ate / -