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HomeMy Public PortalAbout5438 ENCINITA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby,.affirm•thot I have a certificate of consent to self in- 20-0026 DPW 4/90 76A667A• .sure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof (Sec 3800, Lab. C.) e COUNTY OF LOS ANGELES' DEPT. OF PUBLIC WORKS Policy No. --'* Company �� �cacn.f� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESS �� department. ]] NUMBER FIXTURE OR ITEM @( FEE LOCALITY ty Dote ���6 '`C(5 Applicant;�.hmPy f-1\ 4 WATER CLOSET(TOILET) J NEAREST ?y �� �� CERTIFICATE OF EXEMPTION FROM WORKERS' 4 BATH TUB ID CROSS ST. BM__&7dy COMPENSATION INSURANCE SHOWER' OWNER J3iMS Ii & La (This section need not be completed if the work involved by 1 MAIL the permit is for one hundred dollars($100)or less.) 6 LAVATORY ADDRESS 4-/()C) hiller I certify that in the performance of the work for which this per- 2 SINK /G CITY rl' T�Jl2 City TEL. N c mit is issued, I shall not employ any person in any manner so ',r+O as to become subject to the Workers'Compensation Laws. 1 DISHWASHER �' CONTRACTOR lV: _le H,111C;= II" Date. Applicant 1 CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS 47W TLluex BiZVC SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY,, TE . 018) sation provisions of the Labor Code,you must forthwith comp- 1LAWN SPRINKLER SYSTEMS ��' 50=1 927 ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATERLICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION O DISTRICT NO. 6PA I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM 41 OUTLETS �' r+ 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER J and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL V fect (,09(51 /�� a HOSE BIB DATE -71 y. License Number 100`1-11 Lic. Class O FINAL __ U Contractorl!�D�N� �� U.Dote BY I am exempt under Sec. B.&P.C. for this reason• U ''_Ia1�1 LU Date: 4. PLUMBING PERMIT ISSUING FEE$ ► ;13-1 A(_ 4.36 -B. Signature ?-' 4.36 TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and l.•`'':ti•.`(U,I ,OLD Professions Code): 11 Address I, as owner of the property, will do the work and the City Tel. No. __`; i' E_M structure is not intended or offered for sole(Section 7044, �'#`� {�`t r•:- _ Business and Professions Code). , s{_3� � �;M �.; CONSTRUCTION LENDING AGENCY I hereby off irm 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 property for inspection purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE nat a of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby, affirm that I have a certificate of consent to self in- 20-0026 DPW 4/90 76A667A sure,•or a certificate gf Workers'Compensation Insurance,ora L,UI certified copy thereof (Sec. 3800, Lab. C.) _ L4� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company er ified c s hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY 1p j Date Applicant J WATER CLOSET(TOILET) -� NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' ( BATH TUB CROSS ST._ COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL '` the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS �� ( /a�{ V I certify that in the performance of the work for which this per- iiW � mit is issued, I shall not employ any person in any manner so SINK CITY C("�, TEL. N _� as to become subject to the Workers Compensation Laws. DISHWASHER CONTRACTOR Q � Date Applicant CLOTHES WASHER ( ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- tion,you should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR em P Y I P CITY ' TEL. NO. sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATEO LIC. ed. WATER HEATER LICENSE NO. 3 CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRPIESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS pn©fir 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINALTION fect. G HOSE BIB DATE ��(? >- License Number Lic. Class_ 3303 91°700- p FINAL y Contrac� ��it�4af s BY C_ 1 ITEMS cc I am exempt under Sec. TOTAL 9 :1 c 702 B.&P.C. for this reason CHECK 91070 Plan check fee Lu a 00 g Dater CHANGE PLUMBING PERMIT ISSUING FEE$ 136 Signature TOTAL FEE �t�� SINGLE FAMILY Plan check applicant Li1DOG-0001 12/ 7/95 HOME OWNER-BUILDER DECLARATION pp �¢y 1 A�110=��1 I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and Professions Code): Address ❑ I, as owner of the property, will do the work and the City Tel. No. 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 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 re resentatives of this County to enter upon the above-m oned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of er itt a /7 Date