HomeMy Public PortalAbout5702 AGNES AVE_Plumbing_10/12/1984 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, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished.❑ // C /cam FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 25 Ct ✓a-- s" ` 4�%" /'r`S
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER 4
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars($100)or less.) LAVATORY MAIL
J'
I certify that in the performance of the work for which this ADDRESS
permit is issued, I shall not employ any person in any manner SINK CITY r TEL. NQ-
so
so as to become subject to the Workers'Compensation Laws.
DISHWASHER+
(�// //��J/ �///J� CONTRACTORcs�t�
DateZ /?-_�KApplicant2�. _ CLOTHES WASHER cs
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of �� G?�t S J••
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY / -TEL. NO. .
Compensation provisions of the Labor Code, you must forth-
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE1t c�' LIC.
deemed revoked. WATER HEATER LICENSE NO. .S'�o �[J"6 CLASS Zr Jto
LICENSED CONTRACTORS DECLARATION DISTRICT NO. OR410ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS -
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL i VALIDATION
License Number -� /�Z rF 4K Lic. Class G'3� DATE S M
Contractor Date It/0— �1 BY A
❑ I am exempt under Sec.
B.&P.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name -20869A
I hereby affirm that I am exempt from the Contractor's License Address 5Law for the following reason (Section 7031.5, Business and # a o o ° °
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the ) o - 1650(j Jr Q
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
o 0 0 16505
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 1 (112-84
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
above-mentioA�prdy r inspection purposes.'���'�c � SEE REVERSE FOR EXPLANATORY LANGUAGE
e ra
Signature of Permittee Date