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Home My Public Portal About5803 ENCINITA AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 0-0026 76A66A 9/69 APPLICATION FOR PLUMBING PERMIT IJ I hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab. C.) - COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No. Company r_1 Certified copy is hereby furnished. BUILDING r F-1 1-4 Certified APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS O Certified copy is filed with the county building inspection �jg department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Gjr Date Applicant WATER CLOSET NEAREST r, CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB ASSESSOR COMPENSATION INSURANCE (This section need not be completed If the work Involved by the SHOWER MAP BOOK I PAGE PARCEL permit is for one hundred dollars($100)or less.) LAVATORY OWNER /5 r G D I certify that in the performance of the work for which this permit MAIL �] L is issued, I shall not employ any person in any manner so as to SINK ADDRESS become subject to the Workers'Compens tion Laws. DISWASHER CITY C TEL.NO. a 10 Date yn✓�+^�'�� Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this C tificate of CONTRACTOR 1 Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. I LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. (L I hereby affirm that I am licensed under provisions of Chapter 9 STATE LIC.WATER HEATER (commencing with Section 7000) of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. CLASS 0 Professions Code, and my license is in full force and effect. OUTLETS OVER DISTRICT NO. PROCESSED BY ir 5 PER SYSTEM O License Number Lic.Class IF- C' FINAL VALIDATION W DATE _9 _ (L Contractor Date . ..- y rA FJ _ FINAL i=1f:L l.T Z I am exempt under Sec. BY r Q 33n ,7.'_I B.BP.C.for this reason Data: ` Plan check fee ® iTEM'- Signature PLUMBING PERMIT ISSUING FEE$ / (' TOTAL 57 -30 ❑ - TOTAL FEE t ;HUX c/.GI, SINGLE FAMILY Plan check applicant CHANGE r(l� HOME OWNER-BUILDER DECLARATION Name ouQ AA CH I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address p T f coda): IJUpi tt—pIJQ 1 7, El 1, �a Tel. No. �Z41 rAN I,as owner of the property,will do the work and the structure LI"-'JL7� 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 anter upon the above-mentioned pr ert f r ins a Io ur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE Sigka ure of Permittee Date WORKERS'COM?ENSATION DECLARATION APPLICATION FOR PLUMBINGI®ERMIT hereby,•affirm that I have a certificate of consent to self in- 20-0026 DPW 4/90 /'Y lr lL \eP'8 Y IICI FOR PERMIT II sure,ora certificate of Workers'Compensation Insurance,ora certified copy thereof (Sec. 3800, Lab. C.) ' COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy Nc994965 Compa4ep• Indemnity Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING 5803 - ENC INITA AVE7LE Certified copy is filed with the county building inspectionADDRESS department. yme9(-L NUMBER FIXTURE OR ITEM @ FEE LOCALITY 1' CA WATER CLOSET(TOILET) 3, ' ,S e Dat�j/2493 Applicant & NEAREST CRO55 5T. CERTIFICATE OF EXEMPTION FROM WORKERS' � BATH TUB � �� - COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed If the work Involved by MAIL 2 the permit is for one hundred dollars($100)or less.) LAVATORY - Q ADDRE51894 Larkfield Avenue I certify that in the performance of the work for which this per- SINK _ CITdLLCadia, OA T�L.7tAtr. 7267 mit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. / DISHWASHER CONTRACTOR Frank Marrone & Sons, Inc. Date Applicant CLOTHES WASHER ADDREa860 Lower Azusa Rd. NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption, you should become subject to the Workers'Compen- _ CITY E 1 Monte 81 - 2548 sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed-revok- _ STATE 397884 LIC. C/36 C/16 ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION - - .� DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS D p 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER G . and Professiod59ERSYSTEM s Code, and my license is in full force and ef- FINAL VALIDATION fect. 3 C/36 C/16 HOSE BIB DATE License Numba er97884 Lic. Class } FINAL 0 Controckr Marrone & Sons D.42/31/92 . . BY _. 9 cc F-1i.�T,r t- I am exempt under Sec H B.&P.C. for this reason - L- U Plan check fee ,"�I''7 y a Date: _ .1TEIS W PLUMBING PERMIT ISSUING FEE$ ? it Signature TOTAL FEE �til�1- �� "'_-t SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant t-1'E1•� --- 1 hereby affirm that I am exempt from the Contractor's License Name L:HECK Low for the following reason (Section 7031.5,Business and . 1-I NCT Professions Code): � Address .� n +--, Ell, as owner of the property, will do the work and the City Tel. No. structure is not intended or offered forsole(Section 7044, Business and Professions Code). - r CONSTRUCTION LENDING AGENCY ® r 4('lcY i Ail 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 property for inspection purposes. - ��/(j�(�� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o4ermittee Date