HomeMy Public PortalAbout5128 AGNES AVE_Plumbing_0 y WORKEJZS COMPENSATION DECLARATION `
20 0026 DPW 4/87" APPLICATION FOR PLUMBING PERMIT
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I hereby cffirRFYthat I have a certificate of consent to self m �
,. �76A667A ,
sure or a ccxtificate of Workers Compensation Insurance or a CE 817(REV 8/86)
certified copy thereof (Sec 3800 Lab C )
ry COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No Company a r
Certified copy is hereby furnished -r
� a FOR APPLICANT TO FILL IN (PRINT OR TYPE) a BUILDING o2 GM A 19 y y
Certified copy is filed with the county building inspection ADDRESS `�� A �S, (/[�j +
F-
department r1 P Y p z r a{ NUMBER L FIXTURE OR ITEM` Ca FEE LOCALITY ��
` WATER CLOSET(TOILET) J
Date r ` Applicant O� NEAREST w <- n +fa
r t ', O1 ve>4 - _
a� `F CERTIFICATE OF EXEMPTION FROM'WORKERS F `t BATH TUB a ` t n 0. CROSS Si J
COMPENSATION INSURANCE /, OWNER y���{
t 3 1,ye ' ' ,, ySHOWER _ o- F` s'r V rY/fD, 1 Jw L V
(This section need not be completed if the work involved by MAIL
the permit is for o'ne hundred dollars ($
100)or less') e LAVATORY ' g ` 1 -700 ADDRESS
I'certify that in the performance of the work for which this per r - e
mit is issued I shall not employ any person in any manner so a SINK CITY TEL NO t� a
,.as to become subject to the Workers Compensation Laws r� DISHWASHER ^1
CONTRACTOR
Date s o �Applicant ��2(t� �I Q�fX CLOTHES WASHER i Q Ia
t
NOTICEJ0,APPLICANT If'after,makmg this Certhficate,of Ext F SWIMMING POOL RECEPTOR ADDRESS �AA It
a
emption you should become subject to the Workers Compen I ' CITY TEL NO fr
sation provisions of the Labor Code you must forthwith comp v LAWN SPRINKLER SYSTEM t 'G
ly_with such provisions or this permit shall be deemed revok - STATE - UC
ed' z' * ,kr + F WATER HEATER r LICENSE NO CLASS
k#? LICENSED CONTRACTORSlDECLARATION DISTRICT NO PROC D BY
I hereby affirm that I am licensed under provisions of Chapter 't GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business ' OUTLETS OVER«
and Profegsions Code and my license is in full force and of 5 PER SYSTEM FINAL f �� VALID l6N q r O
fect x 7 s DATE d
License Number Lic Class t a n U
F e
cc
Contractor, '^ r Date' ` a " " O
M,
4
aham exempt underiSec " F ;99206A W
'B 8P C for this reasonF a a o o^oro 0 5 rw N
Plan check fee 6 , 4
` ` a Date r ° r PLUMBING PERMIT ISSUING FEE $ a s o o'3 4,5 0
� Signature L 1 � '" ` ' ' _ " -+
- TOTAL FEE } 00034,505
SINGLE FAMILY
t - HOME OWNER BUILDER DECLARATION Plan check applicant _ 03, 19-88
I hereby affirm that I am exempt from`the4Contractor s License Name
Law forrthe following reason (Section 7031 5 Business and
Professions Code) � s a Address
xr � t Fps •' r z~h + ° ` „, .. .. .i
j,-y I ras owner,'of the property will do the work and the City, , Tel No
u structure is not intended or offered for sale(Section 7044 a M v r F x nJ
el Business and Professions Code) t
/r CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
th`e performance of the work for which this permit is issued
a (Sec 3097 Civ C )
Y
Lender s Name
Lender s Address
I certify that I have read this application and state that the
above information is correctyl agree to comply with all County ►
ordinances andY State jaws regulating Plumbing and hereby i. _
authorize representatives of this County to enter eupon the
above mentioned propert for inspection purposes
' SEE REVERSE FOR EXPLANATORY LANGUAGE S '
Signature of Permittee Date y