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HomeMy Public PortalAbout6351 ENCINITA AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION $ ., APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent 5o self j6A667A insure, or a oerlificate 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. BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) Certified copy is filed with the county building inspec- ADDRESS /(/ !' r tion deportment NUMBER FIXTURE OR ITEM @ FEE - LOCALITY Date AppliSanl WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. D / COMPENSATION INSURANCE OWNER (This section need not be completed if the work Involved by SHOWER i MAIL the permit is For one hundred dollars ($/00)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this r permit Is issued, I shall not employ an person in an manner SINK CITY TEL.NO. P P Y Y P Y - so as to become subject to the Workers'Com en n 1.07s. J DISHWASHER CONTRACT Dale :W Applica s CLOTHES WASHER ADDRESS Jr— NOTICE TO APPLICANT: If, after mo nd-this ertificote of .F- Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY TEL. NO. with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE LIC. deemed revoked. WATER HEATERpVe �— LICENSE NO, CLASS LICENSED CONTRACTORS DECLARATION ry, DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINALd DATE 7/ VALIDATION O License Number Lic. Class V FINAL 09 Contractor Dore BY 0 F-1 % W I am exempt under Sec, U B.BP.C. for this reason N Plan check fee D Date: PLUMBING PERMIT ISSUING FEE$ ' Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Low for the following reason (Section 7031.5, Business and n .3 8 CJ, 2 p Professions Code): City Tel. No. ' ❑ I, as owner of the property, will do the work and the 14 a l0 0 0 - 5 structure is not intended or offered for sale (Section 7044, Business and Professions Code). , CONSTRUCTION LENDING AGENCY o�o - .5 a, rj 0.6 I hereby affirm that there is a construction lending agency for 1 ' the performance of the work for which this permit is issued O B 2 9—8 4 (Sec. 3097, Civ. C.). - Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with ail County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the tiY above- stoned roper or i pection purposes. ( - SEE REVERSE FOR EXPLANATORY LANGUAGE S� 5 Signalure/6f Per itte Dote A WORKERS' COMPENSATION DECLARATION - APPLICATION PPL IC p TION F®p PLUMBING L, AppalN PERMIT I here affirm that I have a certificate of consent to self in; 76A,556DPw a/B]- /'9 L �i P'i Y\'I Y'( 4i�N� YCI'�9 Y'(CV7 L I bY� CE 81 7( sure,or a certificate of Workers'Compensation insurance,ora CE 817 (REV'. a/ebj certified cop}yhereof (Sec. 3800, Lob,C ). - i - - • � L ' - COUNTY OF LOS.ANGELES' DEPT. OF PUBLIC WORKS Policy.No. Company - Certified'copy is hereby furnished'. - - 'FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 4z Certified copy is filed with the county building inspection - ADDRESS (G U ; NUMBER FIXTURE.OR ITEM FEE LOCAL ITV 47 `❑-,department.- - _ C WATER CLOSET CLOSET(TOILET) ,.Date N - A licant - •� PP - EAREST CERTIFICATE OF EXEMPTION FROM WORKERS' - BATH TDB ERoss ST. pn/ 10 COMPENSATION INSURANCE ' OWNER 'SHOWER (This section need%not be completed if the work involvedby - MAIL - 'the permit is for one Kindred dollars($100)or less.) LAVATORY ADDRESS - -- "I certify that in the performance oflhe work for which this per- - _ - mit is'issued, shall not employ any person-i n-any manner so SINK•: -• CITY 'TEL. NO, as to become subject to the Workers' Co pensatio DISHWASHER 'r •-- (/ri'La - CONTRACTOR Date' �' Applicant - rte '- ' CLOTHES WASHER ADDRESSUv / NOTICE TO.APPLICANT: If, after 16king1is Certificate of Ex- - - ernption,•you'should becomesubject todhe Workers' T= SWIMMING POOL RECEPTOR - CITY ret No. sdtion provisions of the Labor Code,.you most forthwith comp- LAWN.SPRINKLER SYSTEM ly with such-ibrovisions or.thispermit sholl-be deemed revok- STATE LIC. ed.•, ' - _ _ -WATER HEATER UCENS6N0. CLASS "LICENSED CONTRACTORS DECLARATION - �. DISTRICT NO. / PRO 55ED' I hereby offirm•that I am licensed LiOder provis ons of Chapter' GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the,Busi ness. OUTLETS OVER and Ptofessions Code; and my.license is in lull'fo-rce-ond ef- 5 PER SYSTEM. FINAL , ,+(' VALI TION a Y - DATE i License Number' L¢. Class O U cc Contractor- Dote O I amexempt under'Sec.- W - - :- IL 8 BP.C; for this reason ' N . Plan check fee, - ' - - Date: -`- ; PLUMBING PERMITISSUING,FEE$ V — D z t Signature 'TOTAL.FEE - .114 1 07.6A ^ SINGLE FAMILY- ' HOMEOWNER-BUILDER.DECLARATION• - Plao-check applicant - '_ ' a e 5 I hereby affirm that Iam exempt from the Contractor's License Name RE"X f Low for the following reason (Section 7031.5, Business and - rr Professions Code): - Address .S.S^ �. /1{'�//V - - (te e1 650 S71 I, as owner of the property, will do the work and.the Ciry PM ���. �) Tel. No?Si7 �- structure isnot intendedor offered for sale(Section 7044, :':e'e''e � 6,5 0 Bosiness dnd Professions 11.0 88 Code)... ©' - CONSTRUCTION LENDING AGENCY ' Ihereby,6ffirm 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 information is correct. I agree to comply with all County ordinances ond'State Jaws'regulating.Plumbing, and hereby aut Drize repre n a bf this County to;enter upon the _ a ve�mentibne roperty o)inspectiompurposes. - - - -/i,. 7,^ � SEE.REVERSE FOR EXPLANATORY LANGUAGE - Signature of Permiiee Date '