HomeMy Public PortalAbout5946 ENCINITA AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION P`rPPU`l.A 11 N FOR Ir IL'LJ'tltl11MIG P IGY'lM 0
I hereby affirm that I have a certificate of consent to self 76AM7A
insure, or a certificate of Workers" Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3800, Lob. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company '
C tified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the rWbunspecADDRESS /do p rime + ,� NUMBER FIXTURE OR ITEM @ FEE LOCALWATER CLOSET
Date Applicant �• NEAREST
ERTIFICATE OF EXEMPTION FRBATHTUB CROSS ST.
COMPENSATION INSURANCE - OWNER
(This'section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars.($100)or less.) LAVATORY MAIL
ADDRESS
I certify that in the performance of the work for which this ��
permit is Issued, I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRALTO
Date Applicant CLOTHES WASHER _
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
you Exem tion, should become subject to the Workers SWIMMING POOL RECEPTOR
P Y
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL. NO.
with comply with such provisions or this permit shall be STATE LIC, /J �
deemed revoked. WATER HEATER LICENSE NO. Lill CLASS l� <D
LICENSED CONTRACTORS DECLARATION - DISTRICT NO. PROCESSED BV
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Cade, and m 'cense is in full force and effect. 5 PER SYSTEM FINALIL
DATE �� VALIDATION O
License Number Lic. Class V
�pI /� FINAL
Contractor "v �` Date _ BY V V
❑ W
1 am exempt under Bec. ® so
B.BP.C. for this reason Plan check fee D '( Zp z
Date: PLUMBING PERMIT ISSUING FEE S /x V
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name t 0 9 7,TA
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and ' o e,o e o 5
Professions Code): City Tel. No.
E] e o
I, as owner of the property, will do the work and the i r 1650
structure is not intended or offered for sale (Section D o 0 0 ) 6 5 0-0
7044, Business and Professions Code). L
CONSTRUCTION LENDING AGENCY 05,04-84
1 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
Lender's_Address
I certify that I havesea Thiapplication and state that the
above in rmatian car,ect. I agree to comply with all County
ordinanc 's and St to ws regulating Plumbing, and hereby
outhoriz re res taf es of this County to enter upon the
abov - nt a pr perry f rinspection put Pas
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign ur p Permit a at