HomeMy Public PortalAbout5436 ENCINITA AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION - APPLICATION FOR PLUMBING PERMIT
hhereby affirm'that f have a certificate'of consent to self in_ �76A°°67A PW x79] + s
sura,ora certificate of Workers'Compensation Insurance,or a. CE 817(REV 8/86).
�r f o thereof Sec.�3800, La¢-G.)
- - COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS"
Policy�Na. � Company,. 1 r��-s'r'aI.,
� '_;Certified copy,is hereby furnished - BUILDING
//^�, FOR APPLICANT TO FILL IN (PRINT OR TYPE) ADDRESS
epgn nt- is filed with the co nry.build ng inspection Y .
deport ent NUMBER FIXTURE OR ITEM � @. . FEE LOCALITY
�•�f"'��( I ,WATER CLOSET(TOILET),,
Date < "� Apphcont � l w,' NEAREST
CROSS 5T. + r 1 "
+s' CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB /VET�Yj
COMPENSATION INSURANCE - -
`•Y. SHOWER _ OWNER .aNDITi f,�ls C=0 �c
(This section,need not be completed if the work,.involved by MAIL 4 t
the permit is for on%e hundred dollars ($100)or less.) LAVATORY A 00
ADDRESS Q�" !'Q �1�
I certify that in the performance of the work for which this per- - SINK
mit is.issued, I shall not employ any person'in any manner so CIiV 9 f� ��p . TEL. NO.j ZLg
os'to becdme•subject to the Workers' Compensation Laws. 'r DISHWASHER
A (Lw•—. •- '
'• - CONTRACTOR /f(jC y[�g gick•G
Date Applicant CLOTHES WASHER _
NOTICE TO•'APPLICANT:1f; after makingfitk;s Certificaterof E_- - ADDRESS
SWIMMING POOL RECEPTOR
emption, you should become subject to'tBe'Work'ers,.Compen- � CITY TEL. NO. -
sation provisions'of the Labors Cade,.you must forthwith comp- LAWN SPRINKLER'SYSTEM
Ay with such provisions or this permit shall be deemed revok- .LIC.. '//
,.ed. � � ` WATER HEATER LICENSE NO. CLA55- 6 -
LICENSED CONTRACTORS DECLARATION _DISTRICT NO. PROC 5SED BY
'I hereby affirm that am licensed under provisions of.Chapter GAS SYSTEM- OUTLETS �Lf�
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER -
s PER.sysTEM VALIDATION
and Professions Code,'and my license is in;full force and of-' FINAL IL
feet. : . �y. I, .DATE
0 j 'p
�OLicens^eJJumDber-r Lic. Claryy^^s - U
N:4!LIYFA�f'�'7MW Y� (( f
IFINAL ',ContractorDate �'N'❑ I'am exempt under Sec. WB.BP,C. for this reason Plan check fee � _
Date: ... ..
- PLUMBING PERMIT ISSUfNG FEE$ '
Signature . .• - :TOTAL FEE
SINGLE FAMILY " .Pln check lin(
HOME^OWNER-BUILDER DECLARATION - aapplicant
5. .. .
hereby affirm.that I am exempt from the Contractor's License .Name �` a
Law forlhe follow ng reason (Section.7031.5, Business and - "" - AC.GT•*.
Professions Code): - -Address -.
3307 94.`0
❑' I, as owner'of'the property, willdo the work.and the City .Tel' No. 1. ITEMS
structure isnot intended or.offered for sale(Section 7044 �-s
'BUS
mass and Professions Code). t - D - TOTAL '94 50
CONSTRUCTION LENDING AGENCY, . ' - - CHECK , ?4.511
I hereby affirm that there is a.construction lending agency for -
the perform once'of'the Work for which this permit is issued - - 1.HANl .013
(Sec..3097, Civ. C.). t -
Lender. Name '
0000-0001~ 9i14f
Lender's Address
5700 1 AM10'10
~ I certify that I have read this application and.state that the D '
above information is correct. I agree Io comply with al6Cou my _
ordinances and State laws regulating Plumbing, and hereby t -
authorize representatives of this County to enter upon,the
a e- enti ed property for inspection pur uses. r
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature of Permittee Date i '