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Home My Public Portal About6031 & 6035 ENCINITA AVE_Plumbing__ v WORKERS'COMPENSATION DECLARATION APPkATQON FOR PLUMBING PERMIT MIT • .'41 heieby affirm that I have a certificate of consent to self 76A567A insure, ar 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 Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS td035� ENGIN ITA AVE tion department. NUMBER FIXTURE OR ITEM FEE LOCALITYWATER CLOSETTEMPLp 5 , �1 ctrY Date Appligant vV NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' 1 BATH TUB 6 CROSS ST. GAR►BALD 1 COMPENSATION INSURANCE I SHOWER , �M81� / OWNER LARRY` "AYNE 5 (This section need not be completed if the work Involved by 6 ,,T 52 MAIL the permit Is for one hundred dollars ($I00)or less.) ( LAVATORY 6 V ADDRESS 6035 E N GI N IT A Ave 1 certify that in the performance of the work for which this �.s permit is issued, I shall not employ any person in any manner SINK CITY TEMPLE T..►T 1 TEL. N0.261"9365 so as to become subject to the Workers'Compie t" n Laws. DISHWASHER 1 13 86 � 'L / �� CLOTHES WASHER � CONTRACTOR JQ$gP1{ A AU6UST Date Applicant ADDRESS y,41 Nr V157A NOTICE TO APPLICANT: If, after mak,/g this Cerci mte of Exemption, you should become su lett to the orkers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY SAN G A BRIE L TEL. N0.28 Fj—g'I"JI LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be ++��LL 15 deemed revoked. WATER HEATER LICENSE NO, J J1 3 S� CLASS 5J LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCESSED BY GAS SYSTEM OUTLETS hereby affirm that am licensed under provisions of Chapter 9 1 V V u (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER y and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL f license Number 351385 Lic. Class P> R C%Nr. 01d7 IPLUMIS1144S FINA 0 ContractorJO96PN A AUGUST Date 113 3�0 BY / / A J V C� V 1 am exempt under Sec. W A. N B.BP.C. for this reason WO plan check fee Dore% > ;23850A PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE O # o e e e o 5 Plan check applicant 1 - - 4650 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License - 46.506 Law for the following reason (Section 7031.5, Business and Address Professions Code): City Tel. No. ❑ 1, as owner of the property, will do the work and the structure is not intended or offered for sale (Section D 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performonce of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address certify that I have read this application and state that the D above information is correct. I agree to comply with all County _ ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the metioned p /$erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 9bove igna/ re of P mule Date I WQrmItfl COMPENSATIONDECLARATIONf corse APPLICATION FOR Ir IL4.1t9tl BPNG PERMIT y I I hereby affirm that,I have o certificate of consent to self 75A667A ILJI insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) 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 ./y� / Certified copy is filed with the county building inspec- ADDRESE- + 2=' tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY TJ_ WATER CLOSET, �A7 Date' Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. /v LQ.P /d��I• COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed If the work Involved by MAIL r� the permit Is for one hundred dollars ($100)or loss.) LAVATORY ADDRESS �. J�,✓0/ /tT�� I certify that in the performance of the work for which this permit is issued, I shall not employ any parson any manner SINK CITY- TEL. NO. ,.� so as to becomq subject to the Workers;pj6nynsation Laws. DISHWASHER CONTRACTOR i Date�Applic CLOTHES WASHER ADDRESS NOTICE O APPLICANT: If, after making thls Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM / with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO�� ROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 / GAS SYSTEM 2 OUTLETS S (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER E and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL QQ VA DATION DATE 9-Lo Q 6 a+ License Number Lic. Class 0 FIN BY /- 12U, Contractor Date BY K O I am exempt under Sec U B.BP.C. for this.reason W .Plan check fee N Date-- PLUMBING PERMIT ISSUING FEE$ V Z Signature 4.9 2 9 A TOTAL FEE Plan check applicant ,e e e o, e 5 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name ;( a e 2? 50 I hereby affirm that I am'exempt from the Contractor's License Low for the following reason (Section7031.5, Business and Address e e e '2'2,5 0 5 Prqfessions Code): City Tel. No. 11. 7'1. I, as owner of the property, will do the work and the 007.1 -86, structure is not intended or offered for sale (Section D 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby offirm 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 hove read this application and state that the D above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby , authorize represent Nyes of this County 10 enter upon the above-me io d rop.rty for inspection purpos SEE REVERSE FOR EXPLANATORY LANGUAGE Signal re of Per ivee gale