HomeMy Public PortalAbout4835 AGNES AVE_Plumbing_9/14/1959 WORKS' COMPENSATION DECLARATION
eb if{kFm that I1have o certificate of consent to self in- 20.0026 DPW 4/87 APPLICATION- FOR PLUMBING PERMIT r^�
76A667A
era a certificate Of Workers'Compensation Insurance,ora CE 817(REV. 8/86)
fied copy thereof (Sec. 3800, Lab. C.)
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 �r
❑ Certified copy is filed with the county building inspection ADDRESS` �rJ YE.
department. NUMBER FIXTURE OR ITEM @ FEE LOCALIT C 1 ry e i I �rC
). l C V
Date Applicant WATER CLOSET(TOILETNEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB d%i CROSS ST. A Z u Z
COMPENSATION INSURANCE VV OWNE
v
(This section need not be completed if the work involved by SHOWER. MAIL
the permit is for one hundred dollars ($100)or less.) Z LAVATORY Q ADDRES
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CIT TEL. NO.
as to become subject to the Workers' Compensation Laws. DISHWASHER
JqV CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS �� (�V�•
NOTICE TO APPLICANT: If, after making this Certificate of Ex,- SWIMMING POOL RECEPTOR V I
emption,you should become subject to the Workers'Compen- CITYTEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM 1
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRO 6ED BY
I hereby affirm that I am licensed under provisions of Chapter GA OUTLETS 60
{/
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER d
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM. FINALVALIDA N >_
fect. DATE
License Number Lic. Class.
C)
Contractor Date BY FINA z 85 6 1 A PC
EJI am exempt under Sec. # ° ° ° ° ° 5 C�
B.BP.C. for this reason
Plan check fee. , I ° - 4-6,50
g
Q, Date: PLUMBING PERMIT ISSUING FEE$ a o ° ° 4 6,5 0 5
SignatureN t /�_4.4r
TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant ) 2.1 O--8 7
1 hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and
Professions Code): Address
( I, as owner of the property, will do the work and the. City. Tel. No.
structure is not intended or offered for sale(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 Pr - ^
Lender's Address
I certify that I have read this application and state that the oil.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 prop for ins p ction purposes.
�' 10 SEE REVERSE FOR EXPLANATORY LANGUAGE QL
Signature of Permittee Date'
)