HomeMy Public PortalAbout6214 ENCINITA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING
PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A gar 9tl01� II CI`LY Ir IG II'19N9 II
iflsure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or o certified copy thereof ( ec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Policy No.-W-'/U-x Companyy.L-r?L...s '�' Tn..cft _.:,
Certified copy is hereby furnished.
® FOR APPLICANT 70 FILL IN(PRINT OR TYPE) BUILDING // l � • . L /Ar
Certified copy is filed with the county building inspec- ADDRESS b fT �• �Ti..L�,�-.1 A Ft '�Q..
tion department. / NUMBER FIXTURE OR ITEM n FEE/f
Dote 174-�i
Q/ �r Appli4a f •� !�"� ✓ NEAREST
'] j WATER CLOSET
CERTIFICATE OF EXEMPTION FROM WORKERS' Z BATHTUB O CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by ..Sa
the permit is for one hundred dollars (5100)or lass.) LAVATORY MAIL Z
r]j ADORES$ l �� L..rte%"1 d •��
1 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 became subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR At,.a •� T
Dole Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of b o d� 0t
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR ry
CITY NO
TEL. .
Compensation provisions of the Labor Code, you must forth- A.S AQ...q,
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE - LIC.
deemed revoked. WATER HEATER LICENSE NO. I ��Z CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT N ROCESSED BY
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 Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
IDATION
DAT7-
License Number1 IJ
4f S 2
7 Lic. Class
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Contractor Alk-c e.. ) ase BY
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❑ 1 am exempt under Sec. ,;9 3 O 1,S A y
B.BP.C. for this reasonZ
Plan check fee s" D # e',e e e . 5
Date: PLUMBING PERMIT ISSUING FEE$ t ( e 02850
Signature
TOTAL FEE pp
O o 0 2 g S O U
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name .Q 8.2 6 8 5
1 hereby affirm that I am exempt from the Contractor's License Address
Law for the fallowing reason (Section 7031.5, Business and '
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 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 slate 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
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date