HomeMy Public PortalAbout4937 AGNES AVE_Plumbing__ � f
WORKER COMPENSATION DEUL'%"'RATIO APPLICATION FOR PLUMBING PERMIT
I_hereby affvm'�fhat I Ilhve a certificate of consent to self 20 0026 DPW 6/87 �a
}ure or"a certificate of Workers Compensation Insurance 76A667A City of Temple City ~
df a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS,ANGELES DEPT OF PUBLIC WORKS
Policy No 6969-OQKany MMIC 15153 >
Certified copy is hereby furnished
d� FOR APPLICANT TO FILL IN(PRINT OR TYPE) t BUILDING
® Certified copy is filed withithe county building inspec ADDRESS 4937 A A
tion department r i NUMBER FIXTURE OR ITEM FEE
n
LOCALITY
Date 4/1/9 ppl,agemeral InstallWATER CLOSET NEAREST
Temple Cit CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST La Rosa Dr ZVe_
COMPENSATION INSURANCE SHOWER OWNER Chong Klm
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less ) — MAIL
LAVATORY ADDRESS 4937 neS Ave,
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY9118:)-286-4354so as to become subject to the Workers Compensation Laws DISHWASHER � r
CONTRACTOR General Installation Co.
Date Applicant ' CLOTHE ,WASHER r ADDRESS
NOTICE TO APPLICANT If after making this Certificate of 6558 West Blvd.
Exemption you should become subject to the Workers SWIMM L RECEPTOR
Compensation provisions of the Labor Code you must forth LAWN SPRI SYSTEM CITY i Angeles TEL NO 753-2541
with comply with such provisions or this permit shall be STATE
deemed revoked WATER HEATER LICENSE NO 151839 CLCA$S C36
LICENSED CONTRACTORS DECLARATION D STRICT NO PR ESSED'BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM e 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 i0 FINAL >'
DATE 23 VALIDATION 01
License Number 151839 r Lic Class C36 U
D �
Contractor W. O. PrnV i n Date 4/91 FBY 0
INAL/)
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❑ r W
I am exempt under Sec U
B EP C for this reason ILL
Fl Plan check fee ® Cn
Date PLUMBING PERMIT ISSUINGFEE$ Z
Signature
r
TOTAL FEE i
i
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License Address
Law for the following reason (Section 7031 5 Business and �L� i�octl
❑Professions Code) City Tel No ' " 1 ITEM`I as owner of the property will do the work and the ITEMS
structure is not intended or offered for sale (Section DID, TI FAL 0 0 50
7044 Business and Professions Code) - i i1 HE;r 0.91
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for t HANGS fli I
the performance of the work for which this permit is issued -
(Sec 3097 Civ C ) `
a 111300-130101 Cl/'Lit/ ,J
Lender s Name
Lender Is 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 represent es of this County to enter upon the
abov e ti ro rty for inspgction purposes SEE REVERSE FOR EXPLANATORY LANGUAGE }
/ 5/I Ol90 ;
Signature of flee Date
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