HomeMy Public PortalAbout4908 AGNES AVE_Plumbing_3/5/1962_ TION
W affirm
that
CI have cerci DECLARATION APPLICATION FOR PLUMBING PERMIT
I here affirm trot I have a certificate of consent to self 76A667A +
I insure,pr a certificate of Workers Compensation Insurance CE 817(REV 10/81) `
I or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company Y
Certified copy is hereby furnished BUILDING
I ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county building inspec
tion department NUMBER FIXTURE OR ITEM ® FEE LOCALITY t
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST ,
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars $100 or less i MAIL
p ( ) ) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CIT TEL NO C
so as to become subject to the Workers Compens tiWLw DISHWASHER /
CONTRA90R
Date pplica CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making t Certificate of SWIMMING POOL RECEPTOR
Exemption you should become subject o the Workers CITY ' TEL NO
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION / DISTRICT NO PJtOCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9
GAS SYSTEM OUTLETS , G//1
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER r d
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL
z� �Y/T VAL ATION V
License Number Lic Class DATE, C•� 11119
FINAL O
Contractor Date
BY U
❑ I am exempt under Sec + IL
N
B&P C for this reason Plan check fee 00. Z
Date
Signature PLUMBING PERMIT ISSUING FEE$ f J CJ 3 %,3Q4 1 R
'l
TOTAL FEE SV
SINGLE FAMILY
Plan check applicant +
•
HOME OWNER BUILDER DECLARATION Name ( • ek1 5
I hereby affirm that I am exempt from the Contractor s License Address
Law for the following reason (Section 7031 5 Business and
Pr6505
ofe s Code) City Tel No
I as owner of the property will do the work and the , Q Q 1 —85
structure is not intended or offered for sale (Section ,
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 )
e
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 is County to enter upon the
above mentio property inspec n purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignatur of ermi t Date