HomeMy Public PortalAbout5827 ENCINITA AVE_Plumbing__ WORKERS'6 COaveuIcTION DECLARATION _.APPLICA►TION FOR PLUMBING PERMIT
'k Hereby, affirm rFi6f !have n cernfi cat e of consent to+self in- 76A667A PW 4 87 f Y9 .
sure,ar a certificate of Workers'Compensation Insur nce,or.o CE 817(REV, 8/86) it
4je/d�cqthereof,(Sec '3eDgLa6-E-) COUNTY OF LOS^ANGELES DEPT: OF'PUBLIC WORKS'
Po icy, ampanyI' ' '
E]
Eeriified'copy is',hereby furnished. e
FOR APPLICANT TO FILC IN (PRINT OR TYPE) BUILDING 0
epartm copy is filed with the county building inspection ADDRESS :507-7 `�,y ar//�/(��/ �
NUMBER FIXTURE ORITEM FEE
'department.. • '@
WI WATER;CLOSET(TOILET( 00
Date .I —� Applicanf '/'` NEAREST ) .,
BATHTUB' . CROSS SL Utu(6 [ I s
CERTIFICATE OF EXEMPTION�'FROM WORKERS'. - _
'COMPENSATION INSURANCE - 'oWNERLI
SHOWER Z1 T -VI yl-
(This.section need not be'completed if the work involved by P
the permitAs for one hundred dollars ($100) or less.) ' LAVATORY .ADDRESS Cts t,�j1 '
certify.that in the performance of the work,for whit h'th is per- - ` ` '
mil I is issued, shall not emplcSINK
iiY y7ony person in any manner so "• - C �02 TEL NO - 2Zt8
as to become subject to the Workers' Compensation Laws: DISHWASHER /r
CONTRACTOR 1t
Date' - 'Applicant , - CLOTHES,WASHER 5
ADDRESS
NOTICE TO APPLICANT If, e*subj o t to this Cert Workers'
Ce of Ex SWIMMING POOL RECEPTOR /
emotion, you should be Labor C8deci to the Workers'Compen - CITY TEL. NO.
sotionprovisioris of the Labor Code,-you must forthwith comp,. � - LAWN SPRINKLER SYSTEM � _
ly.with such provisions or'this permit shall be deemed revok - - _ STATE �J
ed.
' - - v � ,WATER•HEATER
LICENSE NO. ( CLASS
LICENSED CONTRACTORS DECLARATIONISTR T CESS D B ,
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 1'`l�
1
9(com mencing;wi th Serti on 7000),of Division 3 of the.Bust Tess .v OUTLETS OVER 5
and
d Professions Code, and my license is in full force and ef- Sc. ,5 PER SYSTEM FDIAN EL O VALIDATION S
///�^t��-(�� in
• Linen a Nu mbar LIC Class(l _ • G
�,s•����((�� FINAL U
IZ
Contractor ®G - ate ` �Z� - -BY p,
+s lsam exempt under Sec( _ I W
a
B BP.C. for'fh is reason 'r' - W
_ „ - Plan check fee - D II Z
Date: - - PLUMBING. ., PERMIT ISSUING FEE $ -'
- _
Signature
., .. : . . . TOTAL FEE
_ SINGLE FAMILY
HOME-OWNER-BUILDER DECLARATION, Plancheck.applicant .. 5 pp
I hereby affirm that Iam exempt from the Contractor's License Name. - 'IT.�rT.T . .
Law for.the following reason (Section 7031.5 Business and _ `"' - °' '
Professions Code)' • - ;' Address: _ J.�,d7 - 94•50
I,:as owner`of:,the property, will do the-work and the City,, c Tel. No. - 1 i•��5'
.
structure isnot Intended or.offered far sole(Section 7044 .. - - - -
Business and Professions Code).. D - TCTAL 94 .'50
CONSTRUCTION LEND ING.AGENCY a 'f > _ - CHECK -94.50
I hereby affirm that there-is a construction lending agency for ,' _ - GE -013
he performance rof the-v✓ork for which this permit is issued ".
(Sec.,3097, Civ: C.).
'Lender's Name •s ; ,j _ C1Q�-0001 9/14/8?
Lender's
Lender's Address ' - 5698 1 AM10:1)13
I certify that I have read this application and state thatthe
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 '
b e nt pop rt lfor inspection purposes. i �� '
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si oture of Permittee Dale