HomeMy Public PortalAbout5472 ENCINITA AVE_Plumbing__ _)RKERS' COMPENSATION DECLARATION A APPLICATION FOR PLUMBING
ffirm that 20-002hove a certificate of consent to self in- 76A666 DPW 4/87 7RMIT
ce,'ificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
cti t. ea cQRy thereof 5ec. 3800, Lab. C.) J
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS /
Policy No. Company �^"K�� � �C /��! 7
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ����-•�/ ,�. �
V Certified copy is filed with the county building inspection ADDRESS `
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date f� e�_gs Applicani(�F/W �� r � WATER CLOSET(TOILET)
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB _ } CROSS ST. �+r•�y
COMPENSATION INSURANCE SHOWER % OWNER CO()
(This section need not be completed if the work involved by (�� MAIL
the permit is for one hundred dollars ($100) or less.) LAVATORY G ADDRESS , /N
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 (1 CITY f 7 yam/ TEL.
as to become subject to the Workers' Compensation Laws. % DISHWASHER ��
CONTRACTOR n u— L �jw,,rnh
Date Applicant CLOTHES WASHER 1 �1��
ADDRESS ✓"—
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen-
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM CITY j- �✓/ 7E
ly with such provisions or this permit shall be deemed revok- STATE I' LIC. L�
ed. WATER HEATER / Gi LICENSE NO. � CLASS G~3
LICENSED CONTRACTORS DECLARATION C/ DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
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 FINAL VALIDATI N >'
fect. �/� DAT — a
License Number_A5sX1(0 Lic. Class �h O
^^-- FIN U
cc
Controcto4^tLL�l..3k+ kJlbi' ,Dal, 12-0 _- T BY
O
1 am exempt under Sec. W
B.BP.C. for this reason Plan check fee ►
Z
Dote: PLUMBING PERMIT ISSUING FEE $ /
Signature
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
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 representatives of this County to enter upon the
above-mentioned raperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Pe mittee Date