HomeMy Public PortalAbout5117 AGNES AVE_Plumbing_0 WORKERS COMPENSATION DECLARATION r t
r 200026 DPW 4/87 , APPLICATION,FOR PLUMBING, PERMIT
I hereby +affirm that I have a certificate of consent to self in 76A667A , I ¢
sure or a certificate of Workers Compensation Insurance or a CE 817(REV 8/86) c t
certified copy thereof (Sec 3800 Lab C )
Policy No H Company 4° , , COUNTY OF LOS ANGELES DEPT OF PUBLIC,.WORKS
Certified copy is hereby furn shed q r w y
+ � FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
a r y Certified copy is filed'with the county building inspection ADDRESS y
department i NUMBER r FIXTURE OR ITEM , Lla FEE f
x f r LOCALITY
Date' Applicanth i '� s WATER CLOSET(TOILET) ' NEAREST-.-
BATH TUBti x v CROSS ST
„ CERTIFICATE OF EXEMPTION FROM WORKERS
° COMPENSATION INSURANCE 1 t OWNER
iSHOWER 5� ,t
(This section need not be completed if the work involved by MAIL ��� `
the permit is for one hundred dollars ($100)or less ) ) 3 ADDRESS
2 f
{ 9 s s / LAVATORY > v� a
I certify that in the`performancerof the work for which this per
mit is issued I shall not employ any person in any manner so SINK r CITY TEL NO
as'to become subject to the Workers Compensation Laws DISHWASHER
F )} r "br' x r +' i s CONTRACTOR
Date ` T Applicant`` ` c CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT If iafter making this Certificate of Ex a /
emphon;you should become sublecttto the Workers Compen - SWIMMING POOL RECEPTOR y v l e }
r a N _ CITY s TEL
cation provisions of,the Labor Code you must forthwith comp r LAWN4SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok STATELIC
ed o t WATER HEATER LICENSE NO 3 CLASS p '
r LICENSED CONTRACTORS DECLARATION �` k DISTRICT NO PROCESSED BY `
I hereby affirm that I am licensed"under provisionssof Chapter GAS SYSTEM OUTLETS 6 ,
9,(commencmg with Section 7000)of Division 3 of the Business OUTLETS OVER r �, L
and Professions Code and my license is in full force and of 5 PER SYSTEM FINALti a d
fect DATE VAL TION - a
License Number—AlON - Lic Class { y (Oj
�,/��� p Z F
Contracto�i'/6/C��] / te� 7��� 0
Y
❑ I am exempt under Sec , 4 W
B &P C for this reason9 T n*d Y s s ` * " a Cal check fee s 4 g
r
Date PLUMBING PERMIT ISSUING FEE$ -1/
(� p /�
Signature s a �— ti , ��9 Q 2 8PAa
Yf g _ r fi 4 a 1. ri 1 TOTAL FEET S
��MILY`---,
NGLERDECLAR ION m Plan check applicant r ; # o o�o o e 5 s
r I hereby affirm that I am exempt from the Co tracto"r s,License Name ° � e '` 5U $ i e`e
Law for'the following reason (Section 7031 Business and - a a y �# sti 2r 5'0
Professions Code) Address ae o 0 2 8 5 0
* �t I as owner of the property twill do the work and the City F ^T r>' ,, Tel `No rr' ; w '_ X42 2'3�$8J M
structure is not intended or offered for sale(Section 7044 a r
Business and Professions'Code) s
r
t� CONSTRUCTION LENDING AGENCY s t' 0
I hereby affirm that there is a construction lending agency for >
the performance of the work for which this permit is issued
Civ'C
(Sec 3097' ) r u i r k W 11 ^ * 4 ,� a ; r
l 4 c eye
� Y e
Lenders Name 'L
l>, � y7}/b e4 o-r "' Q r 1 1 'N A x H � �,I 7abrh �.T � j T 'Lr t• n -�3 ��^' W+ �`Y t"d'
Lender s Address YT - r ,
I certify that I have read this application'"and state that the t µ + t
above information is correctk tm
agree to complytwith all County
ordinances and State laws regulag'Plumbing and hereby
`authorize r resentatives of this,
County to enter upon the i
above entio e t spection purposes a a y t K
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign re of P mittee Date