HomeMy Public PortalAbout5825 ENCINITA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
'It hereby, aifirm that 1 have a certificate of consent to self I. ��67APW 4/87
surd,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) r
PPat
f c there (Sec. 3800, L^H r T_ "
j°�p3(p6e YY1.eu COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
of icy o. Com pony. _Js-
Certified copy is hereby furnished. - BUILDING
FOR APPLICANT i0 FILL IN(PRINT OR TYPE) 'C AI ITI �^c,t-'qq
ertified copy is filed with the county building inspection ADDRESS Sf3 (/ ,� `-
�,de artmenL NUMBER FIXTURE OR ITEM @, FEE .
LOCALITY
/�-$� r WATER CLOSET (TOILET) / � IK l..l
Do 07 NEAREST Q
BATH TUB �y CR055 ST. J
CERTIFICATE OF EXEMPTION FROM WORKERS' 0 - At
s�
COMPENSATION INSURANCE SHOWER - OWNER At r�
(This section.needn4 0 ot be completed if the work involved by n /� MAIL (1�
the permit is for ono hundred dollars ($100) or less.) LAVATORY-• ADDRESS
I certify that in the performance of the work for which this per- 1 SINK
mit is issued, I shall not employ any person in any.manner so L CITY s C"'Il' TEL. NO ' I g
as to become subject to the Workers'Compensation Laws. ` DISHWASHER - L-C
CONTRACTOR
Date Applicant CLOTHES WASHER b
NOTICE TO APPLICANT: If, after making this Certificate of Ex- AI
ADDRESS 7
em tion;you should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR /
P Y I P CITY IoLJ -: // TEL.NO.
cation provisions of the Labor Code, you must forthwith comp- .LAWN SPRINKLER SYSTEM N LOCK
ly with such provisions or this permit shall.be deemed revok- STATEP LIC.
ed. ' - - t WATER HEATER LICENSE NO. O `CL455
LICENSED CONTRACTORS DECLARATION DISTRICT NOOCESSED BY
'. .
I hereby affirm that GAS SYSTEM am licensed under provisions of Chapter ' OUTLETS __25 .t
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
d Professions Code, and my license is in full force and ef- 5 PER.SYSTEM : FINAL ALIDATION d
fe
f ass DATE �':
Liceaie Number Lic. Cl
v_ U
CBPPRo r11 FINAL i Q
Contractor t/ �- Date� BY - t O
I am exempt under Sec.
CL
B.BP.C. for this reasonD Z
Plan check fee -
Dote: PLUMBING PERMIT ISSUING FEE.$ -
Signature TOTAL FEE67)
SINGLE FAMILY •
HOME OWNER-BUILDER DECLARATION Plan check applicant _. .'rjsr
I hereby affirm that I am exempt from the Contractor's License Name QCCT.i
Law for the following reason (Section 7031.5, Business and - '
Professions Code): " Address - - 73307 Ctrt� 94.30
DI; as owner of the property, will do the work and the City Tel. No.. 1 ITEr3
structure is not intended or offered for sale(Section 7044, 9.4:..
s EI.
Business and Professions Code). - - TOTAL
CONSTRUCTION LENDING AGENCY D , CHECK ' 94•513
1 hereby affirm that there is o constructionlending agency for CHANE s00
the performance of the work for which this permit is issued
(Sec 3097, Civ..C.).
Lenders Nome �0L000�0OOI 9/14/39
•1
Lender's Address 697 1 AM 10:10
I certify that 1 have-reed this application and state that the
above information is correct. I agree to comply with all County .. D
ordinances and State laws regulating Plumbing, and hereby
authorize representatives.of this County to enter upon the -
boveam tinned roperN'for inspection p�ses.�
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ature of Permittee Dote