HomeMy Public PortalAbout5942 ENCINITA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION renesrn
I herebyO.Tfirm--that I have a certificate of consent toself . cE en (,..) " APPLICATION FOR - PLUMBING PERMIT
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800, Lab, C.)
COUNTY OF LOS ANGELES � BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING 1
❑ NUMBER FIXTURE OR ITEM O FEE,
ADDRESS
Certified copy is filed with [he•county building inspection
department. WATER CLOSET LOCALITY �. t
Date Applicant NEAREST
BATHTUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER 3 OWNER r ti
MAIL
(This section need not be completed if the work involved LAVATORY ,3 - ADDRESS F d
by the permit is for one hondred dollars ($100) or less.) SINK - O
CITY TEL. NO. O
I certify that in the performance of the work for which this DISHWASHERX
permit is issued, I shall not employ any person in any manner CONTRACTOR Lkr _ a/} �✓ O
so to to become object to th t C ?n�'n Laws CLOTHES WASHER 1YJ202 SWIMMING POOL RECEPTOR ADDRESS
Date -ll fi Applicant 6 ;0.
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL. NO.
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE +LIC.
Compensation provisions of the Labor Code, you must forth- - LICENSE NO. C— ��--`� CLASS G
with comply with,such provisions or this permit shall be WATER HEATER
deemed revoked. - DISTRICT NO. PR CESSE4BV
GAS SYSTEM OUTLETS .3
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code, and my license is in full force and DATE
effect. -
_ FINAL
License Number O��Z—� ""L��i��c��. Class C � BY
I am exempt from the licensing requirements as I am a Plan Check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
-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 T.I.No. -
ness and Professions Code):
0,7 1.3 A
I, as owner of the property, am exclusively contracting -- -
with licensed contractors to construct the project # a e.e o e rj
(Section 7044,Business and Professions Code).
2 e"e 1 9.00
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency .e e,o 1 9,0 Q6
for the performance of the work for which this permit is ,
issued(Sec. 3097,Civ.C.).
8. 1 , _8 1
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
;b�vtproperty inspection purposes.
Se f rmi ee Date