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Home My Public Portal About4901 AGNES AVE_Plumbing_4/30/1959_ , fA `tt101�KERS"COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT r by,gffikm that I heave o c611ftcatetaf consent to self 76A667A ns re, or a certifirdre of*t orkers Compensation Insurance, CE 817(REV. 8/86) or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. 1•p01. N. Agnes Ave. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- 49 ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY emp a City, Ca. Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS.ST., Lower Azusa COMPENSATION INSURANCE SHOWER OWNER Youn K. Kim (This section need not be completed if the Aork involved by MAIL the permit is for one hundred dollars 10 )or less.) LAVATORY ADDRESS Same I certify that in the performance oftork for w Ah this permit is issued, I shall not employ any son i�f any a ner SINK CITY Te le •t TEL. NO. 286-008 so as to become subject to the Worke p�rg"at' ws. l DISHWASHER t'�/ CONTRACTOR Self Date 6/3/87 Applicant O Kim CLOTHES WASHER NOTICE TO APPLICANT: If, after a ing this Certificate of ADDRESS 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 STATE LIC. deemed revoked. 1 WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT N PR 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 1 water line refri o 1 DATE License Number Lic. Class FINAL Contractor Date BY ❑ I am exempt under Sec. LU I� B.BP.C. for this reason Plan check fee ® g Date: PLUMBING PERMIT ISSUING FEE$ Signature ;271 5 6 A TOTAL FEE Plan check applicant # o a o a o 5 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I o a 3 4,5 0 1 hereby affirm that I am exempt from the Contractor's License _ Law for.the following reason (Section 7031.5, Business and Address o o.. 3 Q.5 0 51 Professions Code): Cit Tel. No. © I, as owner of the property,.will do the work and the y o &03-87 structure is not intended or offered for sale (Section a 7044, Business and Professions Code). 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 ► 4autr� mation is correct. I agree to comply with all County and State laws regulating Plumbing, and hereby presentatives. of this County to enter upon the i ed poperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 6/3/87 Permittee Date