HomeMy Public PortalAbout5136 AGNES AVE_Plumbing_0 WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 20 0026 DPW 6/87
Insure or a certificate of Workers Compensation Insurance 76A667A
or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No Company ' - { f
Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 1 /5
Certified copy is filed with the county budding inspec ADDRESS
tion department NUMBER r FIXTURE OR ITEM @ FEE LOCALITYCL
Date Applicant WATER CLOSET NEAREST f
CERTIFICATE OF EXEMPTION FROM WORKERS
P BATH TUB CROSS ST f!o 4 n vt
COMPENSATION INSURANCE
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(This section need not be completed if the work Involved by l SHOWER V bMAIL
OWNER
the permit is for one hundred dollars ($100)or less ) LAVATORY 6 ADDRESS M
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner o SINK CITY TEL NO2 „ �l
so as to become subject to the Work e s Compensation Laws DISHWASHER ,`� 7
+ d CONTRACTOR Ll (�
Date ::� Applicant CLOTHES WASHER ^
NOTICE TO APPLICANT If after making this Certificate of ADDRESS Z /✓ AZ V
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR A �
CITY l'�C3 UJ i�� TEL NOS
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked d WATER HEATER LICENSE NO CLASS 16
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS D (�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER d
and Professions Code and my license is in full force and effect 5 PER SYSTEM
` gg FINAL VALIDATION n:
License Numbers DATE
Lic Class " G U
FINAL
Contractor dlL� �'s�t' 9F z �Al BY Q
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I am exempt under Sec � W
B 8P C for this reason Q.
Plan check fee ® Z
Date
�� �� pp,,�� �� �� PLUMBING PERMIT ISSUING FEE$
Signature����'(/k%//V 1
TOTAL FEE D
SINGLE FAMILY
Plan check applicant
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HOME OWNER BUILDER DECLARATION Name NEL)
I hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and Address Z V T
Professions Code) City Tel No
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I as owner of the property will do the work and the
structure is not intended or offered for sale (Section
7044 Business and Professions Code) E'1 1 r�Ls _ems
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 1 i )7= i
(Sec 3097 Civ C )
Lender s Name i✓1 11 _a i E r " r
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 and State laws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
abo mentione property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date -
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