HomeMy Public PortalAbout5920 ENCINITA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION ranesvn
I herebSaffirm that I have a' certificate of consent to self CE sn (2-60) - APPLICATION FOR PLUMBING PERMIT
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800 La .C.)
COUNTY OF LOS ANGELES BUI DING AND SAFETY
Policy No. Company
0 Certified py is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDI ^
NUMBER FIXTURE OR ITEM O FEE ADDRESS -S
I N Certifi copied with the unty buildin spection
Y� t LOCALITY
WATER CLOSET
NEAREST
BATH TUB CROSS ST. II
CERTI
COMPENSATION
OM PdCE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
LAVATORY MAIL !7
(This section need not be completed if the work involved ADDRESS Cl� a.
by the permit is for one hundred dollars ($100) or less.) SINK _
CIT TEL. NO2 V
I certify that in the performance of the work for which this DISHWASHERcc
permit is issued, I shall not employ any person in any manner CONTRACTOR - Q
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER �j� U
ADDRESSC)q eo
Date Applicant SWIMMING POOL RECEPTOR W
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL NO. e. to
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE nn LIC. �` 2
Compensation provisions of the Labor Code, you must forth- LICENSE NO.t% ISS CLASS
with comply with such provisions or this permit shall be WATER HEATERCO
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. P ESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
r Olt Gl
1 hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL /�� tom/
ness and Professions Code, and my license is in ll force and DATE SON
2
VALIDA
effect. �I
`{I FINAL
License Number Lia Class - BY 1 t
Contractor _ De
ElI am exempt from the licensing requirements as I am a Plan Check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, B1[a-
mess and Professions Code). TOTAL FEE 10
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section 7031.5, Busi- City Tel. No.
ness and Professions Code): ;2 3 5 a 2 A
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project # e e o o e 5
(Section 7044, Business and Professions Code). '
2ee � 0,00
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency �rq 9 A � �e /vera`FVr o o e 0,0 0
for the performance of the work for which this permit is �.,.,T p,B tp ., [f?Ar .�p}L(, eft y z,�
issued (Sec. 3097,Civ.C.). ' ; L UY :1 e�7F`i �i q{�•y: b'ec4v
Lender's Name @'ttr,h-:.(id.' C a'� .1231 -8.0
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordina an lows regulating Plumbing, and ereby
aulho ae representative of this Count u enter n the
o - ned DroDer for inspec 'on p po es
Signature of Permittee Da[