HomeMy Public PortalAbout5219 AGNES AVE_Plumbing_0 WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm 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 Lob C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
❑ Certified copy is filed with the county building mspec FIXTURE OR ITEM ADDRESS --��
Tion department NUMBER � FEE
LOCALITY
Date Applicant c WATER CLOSET NEAREST .H
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB s CROSS ST ,
COMPENSATION INSURANCE SHOWER f OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less ) LAVATORY ADDRESS `!
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY � �� TEL NO �/�(
so as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM CITY TEL NO
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER �� LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER r
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL VALIDATION O
DATE U
License Number Lic Class tM
FINAL 0
Contractor Date BY V
❑ w
I am exempt under Sec �
� N
B &P C for this reason Z
Plan check fee
Date PLUMBING PERMIT ISSUING FEE$ Q
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant -2 3 4 3.2 A
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License Address # o o o 0 0 5
Law for the following reason (Section 7031 5 Business and '
Professions Code) City Tel No 2 ° - 64-50
❑ I as owner of the property will do the work and the - 0 0 0 6(( 5 p U
structure is not intended or offered for sale (Section ,
70414 Business and Professions Code) 0 706-83
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
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 jaws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
a7bo mentioned property for inspection purposes
/X// � / V SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign re of Permittee Da e