HomeMy Public PortalAbout5211 AGNES AVE_Plumbing_0 WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I kereby affi m that I have a certificate of consent to self 76A667A
insure or a certificate 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 [�� o
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
ADDRESS �,4�/ /9� N W V
❑ Certified copy is filed with the county building mspec a
tion department NUMBER FIXTURE OR ITEM @ FEE ,v
p LOCALITY
Date Applicant WATER CLOSET NEAREST n
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE OWNER r ,
SHOWER _� o
(This section need not be completed if the work involved by AIL
the permit is for one hundred dollars ($100)or less ) LAVATORY
ADDRESS S c?-/►? `�'
I certify that in the performance of the work for which this
permit is issued I shall,not employ any person in any manner SINK / CITY TEL N0�8�
71
so as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR
4
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth CITY TEL NO
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER t LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO P ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and effect 5 PER SYSTEM
FINAL _� VALIDATION 0
A
License Number Lic Class of
FIN O
Contractor Date BY r—
V
❑ 1 am exempt under Sec f�
N
B &P C for this reason Z
Plan check fee
Date
PLUMBING PERMIT ISSUING FEE$ s
Signature I
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License Address 2 Q 8 7 9 A
Law for the following reason (Section 7031 5 Business and
Professions Code) City Tel No # 0 0 0 0 0 5
r I as owner of the property will do the work and the ' 2- 1 0 6*5 0
structure is not intended or offered for sale (Section
7044 Business and Professions Code) a0 0 1 d 6,5 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 0 3 3 1 —83
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 and State laws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
aba entioned prop tyZ
pection purposes
n SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature of Permittee Dat
1,