HomeMy Public PortalAbout6261 ENCINITA AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION " APPLICATION FOR -PLUMBING PERMIT
I hereby, affirm that I hpve'a certificate of consent to self in 20-0026 DPW'4/8]
sure,or a'certificate'of Workers'Compensation Insurance,ora CE 81 7( ,ILJII
P CE 817(REV: 8/86)'
certified copy thereof (Sec. 3800, Lab. G)-?
' COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy'No: Company - -
certified copy is hereby furnished_
O FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 6z� �.r F_ c,h L ,1.-A e ')
-,nvi
Certified copy is filed with the county building inspection - ADDRESS r �,
de arimeht. NUMBER FIXTURE OR ITEM @ FEE ( _
Date ' P 'Applicant aC. . WATER CLOSET(TOILET) Oh NEAREST l j�j ,K CALITY
Ct 1 _�
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB V(� CROSS ST. -
'< COMPENSATION INSURANCE .. I SHOWER OWNER
(Th.is.section need not be completed if the work Involved by MAIL wa
the permit is for one hundred dollors /n'1:(9100) or less.) ' LAVATORY - V ADDRESS
I certify that in the performance of the'work for v;hlch,thisper- 'f SINK_ CITv E NO.
mit is issued, shall not employ any person in any manner so -. a0KQ �' �J9.�(I 7 -} -
- astto becomeisdbiect to the Workers' Compensation Laws. DISHWASHER -
CONTRACTO
Date 'U Applicant : CLOTHES WASHER
NOTICE TO APPLICANT:AS, after making this Certificate of Ex- ADDRESS
em tion; ou should'beco me sub'ect tothe Workers'.Com en- SWIMMING POOL RECEPTOR ,
P .Y P.. - CITY TEL NO.
cation provisions of the Labor Code, you must forthwith -LAWN SPRINKLER SYSTEM '
comp-
ly with such provisions''or this permit shall be deemed;revok- - - STATE LIC
ed. _ In WATER.HEATER O LICENSE NO. CLASS '
LICENSED CONTRACTORS DECLARATION' - DISTRICT NO. PROCESSED.BY
hhereby affirm that I am licensed under provisions'of•Chapter 'GAS SYSTEM J OUTLETS
9(commencing with Section 7000)of Division 3 of.the Business OUTLETS OVER - i' o
and Professions Code, and my license is in fulhforce and.ef- 5 PER SYSTEM FINAL VALIDATION Y
."feet. , .. - DATE lop
License Number Lic. Class - U
FINAL cc
Contractor Date
BY O
OJ a'm exempt under Sec. - - W
B BP:C. for this reason - Il
,.h - Plan check fee. ,` D - i
Date: PLUMBING PERMIT ISSUING FEE
�Slgnoture ' a - TOTAL FEE g' S ,
_ - - SINGLE FAMILY ,
- HOME OWNER-BUILDER DECLARATION .Pl.n.check applicant -
5
I hereby affirm that I am exempt from.the Contractor's License Name
Law,for the following reason (Section 7031.5, Business ands: .�16CT.a
Professions.Code): - Address
3307 `-
I, as owner of the property, wlll'do the work and the City r Tel. No.
'structure is not intended or offered for sale(SectIan,7044, - - - 1. ITEMS
i
Business and Professions Code). _ _ .t D TOTAL
t33 - 50 ac0
CONSTRUCTION LENDING AGENCY,
hereby affirm thatIherelis a construction.lending agency for s - 'CHECK �`,�i•S[I
the performance.of the work for which this.permit'is,issued CHANGE" •LIf�
(Sec. 3097, Civ. C.). t -
Lender's Name
boomo0i-
11/23/39
Lender's Address _ - .. - _ 71365 'r1 AN 9�41
certify ihahl have'read this application and state that the ,
above information icorrect.I agree to comply withal]County D r
ordinonces'ond State laws regulating Plumbing;.and hereby - -
authon re resen atives oft s-County gleons4lulpon'the
ab' Ian operty f in pectian -
G
- '1 'j/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig 'of ermlttee Date