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Home My Public Portal About6117 ENCINITA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 1]6A66)A I hereby affirm that I have acertificate of concept to self cE.fiv (a-aa) APPLICATION FOR PLUMBING PERMIT insure. or a certificate of Workers'Compensation lnsuiance,or a certified copy thereof(Sec. 3800, Lab.C.) - , COUNTY OF LOS AN LES e- BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING 1_7 ❑ NUMBER FIXTURE OR ITEM 0 FEE ADDRESS Certified copy is filed with the county building inspection G department LO CALIT WATER CLOSET Date Applicant NEAREST , A/ BATH TUB CROSS ST. LGJ CERTIFICATE EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER L IA ©Q " (This section need not be completed if the work involved LAVATORY gDESS [� a d M by the permit is for one hundred dollus ($100) or less.) SINK CITY"��v 3/ ..7 0 I certify that in the performance of the work for which this DISHWASHER2 permit is issued. I shall not employ any person in•any manner CONTRACTOR O so as to ec Vm�e subject to the/•W rkers' Co ensa[io'n9 Laws. CLOTHES WASHER ADDRESS U <-ate JV71? Applicant N o�C-Z! / SWIMMING POOL RECEPTOR w CITY TEL. NO. 1 NOTICE TO APPLICANT: If, atter making this Certificate of - N Exertiption, you should becomesubject to the Workers' LAWN SPRINKLER SYSTEM STATE - LIC. z Compensation provisions of the Labor Code, you must.forthLICENSE NO. z CLASS with comply with such provisions or this permit shall be WATER HEATER deemed revoked. - GAS SYSTEM - OUTLETS DISTRICT NO, PR CESSED BY LICENSED CONTRACTORS DECLARATION - OUTLETS OVER Si U(J I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL ,�v� VALIDATION ness and Professions Code, and my license is in full force and DATE o effect. FINAL IS License Number Lia Class BY Contractor Date .a F1 I am exempt from the licensing requirements as I am a Plan Check fee licensed architect or a registered professional engineer PLUMBING PERM17 ISSUING FEE$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE Lic.or Reg.No. Date Plan check applicant z 4 6 6 5-A HOME.OWNER-BUILDER DECLARATION Name # o'0 0 0 0 5 Address Vhheb affvm that 1 am exempt from the Contractor's Q e e 3 q;'p Q Law for the following reason (Section.7031.5, Busi- City Tel.No. Professions Code): .o o 0 3 7; 0 0 5 owner of the property, am exclusively contracting with licensed contractors to construct the project 0 i'''O'7—8 (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I 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 have read this application and state that.the above inform is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE rd n� a State laws regulating Plumbing, and hereby [h r(ze r p, ntatives of this County to ente upon the abp4e-meted pert �inspection purpose . ' Sig at r�Permittee Dat