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Home My Public Portal About5803 1/2 ENCINITA AVE_Plumbing__ WORKER'S COMcef DECLARATION 76A66A 9/e9 APPLICATION FOR PLUMBING PERMIT LI I hereby affirm that 1 have.acertificate of consent to self insure, 0-0026 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 ❑ Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ADDRESS Certified copy is filed with the county building inspection department. NUMBER - FIXTURE OR ITEM g FEE LOCALITY C t Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. VYI N COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL LAVATORY p vv permit is for one hundred dollars($100)or less.) OWNER e I Cyt)elo 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as toMAIL SINK ADDRESS 28 / rt:414pt become subject to the Workers'Compensation Law DISWASHER CIN AY64 AQ TEL.NO.fF,74LQ Dale Applicant CLOTHES WASHER CONTRACTOR NOTICET5 AP (CANT: If, after making this C ,ficYoff Exemption,you should become subject to the Workers' Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. Y I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER d (commencing with Section 7000) of Division 3 of the Business and STATE LIC.GAS SYSTEM OUTLETS LICENSE NO. CLASS O ,Professions Code,and my license is in full force and effect. V OUTLETS OVER DISTRICT NO. (7`�� PROCESSED BY Q 5 PER SYSTEM O y Q License Number Lic.ClassL ~ C FINAL j VALIDATION w DATE ...�—g' T d Contractor Date fn ❑ FINAL _[J ice', j{,�ilZ I am exempt under Sea BY h! B.BP.C.for this reason ITEC 1-' Date: Plan check fee > TOTAL 57 - 30 PLUMBING PERMIT ISSUING FEE$ Signature D CHECK 7.9:I ❑ TOTAL FEE CHANGE ,I ill Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION NameH 04461140 W i I hereby affirm that I am exempt from the Contractor's License Law n J 1 QI 00-0001 71, 5119$ far the following reason (Section 7031.5, Business and Professions Address LAYcm. Cade), ` lir• :❑ 1 An '9:41 i City Tel.Na. I,as owner of the property,will do the work and the 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. O) 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 p or inspectio urpose SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Perm ee Date WORKERS'COMPENSATION DECLARATION PLICATION FOR PLIU BIND PERMIT - I hereby, affirm that I have a certificate of consent to self in- 20-0046-0Pw 4/Br /9 LL P9 tl Ytl Y•l Ir IJV VOID Y\7 PERMIT sure, or a certificate pf Workers'Compensation Insurance,ora CE B17 A P '.CE HV(REV 8/86) certified copy thereof(Sec 3000, Lab. C.) " 994965 Rep_ Tnderrl COUNTY OF LOS ANGELES - DEPT. OF P.UBLIC.WORKS Policy Na. Company Certified copy is hereby furnished, '• D _ - , , - FOR APPLICANT TO FILL IN (PRINT OR TYPE) - BUILDING - ® Certified copy is filed with the county ybuilding.inspection ADDRESS 5803 d"epartmen�. � NUMBER ENCINI V DFIXTURE OR ITEM FEE _ • - - @ LOCALITY TEMPLE CITY, CA ' ate '''6/24/93 • Applicant ^ WATER CLOSET(TOILET) 6s NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' ,Z BATH TUB U CROSS ST. COMPENSATION INSURANCE • OWNER. / -HUNG -CHOU & ASSOCIATE - (This section need not be completedifthe work involved bySHOWER. MAIL - the permit is for one hundred dollars ($100)or less.) . LAVATORY' ✓O ADDRESS 2894 LARKFIELD AVENUE - I certify thatin the performance of the Work for which this per- SINK m[0is,issued, I shall.not employ any person in any manner.so CITY ARCADIA TEL..NC574-7267 as to become subject to the Workers' Compensation.Laws. I DISHWASHER - - CONTRACTO RONIT A, Date Applicant In - CLOTHES WASHER ADDRESS 9861) LOWeT. 'AZil$H S Rd. NOTICE TO APPLICANT If,..after making this Ceibficate of:Ex- SWIMMING POOL RECEPTOR' ' •emption,you should beccme.sublect to fie workeis'Compen- CITY EL Monte, TEL, r4p44-2548' scion provisions of the Labor Code, you.must forthwith comp- LAWN SPRINKLER SYSTEM ly.with such provisions or this permit shall be deemed revok-, - - STATE.. 397884 ' ' LIC. •4 ed. t', /. WATER HEATER .S LICENSE NO. CLASS ' l LICENSED CONTRACTORS DECLARATION / 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 fed Professions Code, and my license is in full force and cV. 5 PER SYSTEM - FINAL VALIDATION � •r 6 V DATE C License�N.rri•397884 -Lic. Class C-/36 C/16 _ a - •V FINAL F. Marrone & 'Sonsme 12/31 /9 - BY - Lr } 6 Contrdcror 2 - t -a D I am exempt under Sec � _ G7 Pl2 zEj 6 8.8P.C. for this reasonPlan Check fel - }' �(C' L- y ' _ 8 'Dote:- - PLUMBING PERMIT ISSUING FEE Signature- / [ C.t-le_.}{ f.�;G, r•. - . TOTAL FEE SINGLE FAMILY - .plan check applicant HOMEOWNER-BUILDER DECLARATION pp I.hereby affirm that I.am exempt from the Contractor's License Name Low for thefollowing reason (Section 7031':5, Business and r Professions Cade): Address . . IT tgi. 175°'ff 's.+ ,t,.-; I,'as owner�of the property;will do tha work and the City , Tel. No. `�I'_; _ 'structure is not intended or offered for.sale(Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY - 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 - t Lender's Address r I certify that I have read this application and state.that the - - - - above,informotion is correct:]agree to comply with.all County D ordinances and Stale laws-Fegulating Plumbing, and hereby authorize representatives of this.County to enter upon the ab ov menti ed propetty for inspection,purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of aermittee •' Date _