HomeMy Public PortalAbout4840 AGNES AVE_Plumbing_8/11/1959_ t• WORKERS'COMPENSATION DECLARATION '20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
I hereby, affirm'that I have (7 certifjcase of consent to self in- 76A667A
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
€ertified copy thereof (Sec. 3800, Lab. C.) "fl
Policy No. Company �S V COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
P-'C'ertified copy is hereby furnished. -+rcg11
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING 'w A
Certified copy is filed with the county'buildi pection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
�'��j�q 1 WATER CLOSET(TOILET)
Date F- Applicant NEAREST / s ��
CERTIFICATE OF EXEMPTION FROM WORKERS''
BATH TUB CROSS ST. �jf¢y�
COMPENSATION INSURANCE SHOWER OWNER GV C1xo�
(This section need not be completed if the work involved by MAIL + /p
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY 'c TEL. NO.
as to become subject to the Workers Compensation Laws, DISHWASHER
CONTRACTOR 58 r. S(,�/114S
Date � Applicant � CLOTHES WASHER ADDRESS !�loo l T ���F G►1/0
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY �.R TEL. NO.'71,.75�•�
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE ,/ �pp LIC.
ed. WATER HEATER LICENSE NO, 44�.)�-7 CLASS C�-a
LICENSED CONTRACTORS DECLARATION DISTRICT UO. kAOCESSED BY
hereby affirm that I am licensed under provisions of Chapter
GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
fed Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL V L DATION
DATEILO
License Number Lic. Class V
FINAL
Contractor Date BY O
OI am exempt under Sec. UJI
B.BP.C. for this reason ,
Plan check fee g
Date: PLUMBING PERMIT ISSUING FEE$ 050
Signature TOTAL FEE
SINGLE FAMILY '-` �
HOME OWNER-BUILDER DECLARATION Plan check applicant 1 mNs�rFly
'1
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and �, SIS (�(_t.T,4 .
Professions Code): Address -( V1 VP 33075 1
1�:t a•_
0 I, as owner of the property, will do the work and the City .� Tel. No.'l 4. (� ,�
structure is not intended or offered for sale(Section 7044, .1TEME
Business and Professions Code). , TOTAL 16 tc
CONSTRUCTION LENDING AGENCY {[jjC�( {{
I hereby affirm that there is a construction lending agency-for '
6.513.
the performance of the work for which this permit is issued CHANGE ,1_111
(Sec. 3097, Civ. C.).
Lender's Name IS0'0- 101 11f 6/88
Lender's Address 6586 1 aAMIDacc
I certify that I haves 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-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date