HomeMy Public PortalAbout5112 AGNES AVE_Plumbing_3/9/1982_fixtures, water heater, water heater, gas syst ION
I heWORKER$ at I have a cerci DECLARATION CrE 817 APPLICATION FOR PLUMBING PERMIT
reby affirm that I have a certificate of consent to self ce en (z eo)
insure or a certificate of Workbrs Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C)
A^J�n,OV- 971 COUNTY OF LOS ANGELEt_':e@ BUILDING AND SAFETY
.icy o Company G�L !
c
Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
(� NUMBER FIXTURE OR ITEM • FEE ADDRESS
�r� Certified copy u filed with the county ildmg n pection
epart LOCALITY
WATER CLOSET
Date — Applican � 1NEAREST
BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE t SHOWER OWNER
LAVATORY MAIL >-
(This section need not be completed if the work involved ADDRESS S 7 Z 0-
by
by the permit is for one hundred dollars ($100) or less) SINK O
r
CITY 4� TEL NO � U
I certify that in the performance of the work for which this0 41
DISHWASHER
perm t is issued I shall not employ any person in any manner CONTR OR 4� cc
so as to become subject to the Workers Compensation Laws CLOTHES WASHER ADDRESS
Date Applicant /1 LU
NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR_ CITY � TEL NO tl
7S p�> Cl)
Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE LIC — Z
Compensation provisions of the Labor Code you must forth LICENSE NO 37S9r� CLAS
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked GAS SYSTEM OUTLETS DICT NO, '�;S BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER elQ(/
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi FINAL � j�� VALIDA ION
ness and Professions Code and my license is in full force and DATE (�
effect
' � �t 3 FINAL v
License NumberLic Class BY
Contractor[' Date 6 ' 3
F1I am exempt from the licensing requirements as I am a Plan check fee /
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051 Bus
mess and Professions Code) TOTAL FEE
Lic or Reg No Date Plan check applicant
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractors 5 Address ;23208A
License Law for the following reason (Section 7031 5 Busi City Tel No
ness and Professions Code) , I # oro 0 0 0
❑ I as owner of the property am exclusively contracting 2Yo po 68.50
with licensed contractors to construct the project
(Section 7044 Business and Professions Code) 0 oto 6a505:
CONSTRUCTION LENDING AGENCY 0 0 9-82
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
i
Lender s Address
I certify that I have read this application and state that the H
above information is correct I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing and hereby
authorize re resentatives of his County to enter upon the
a me n property f spection purposes
Signature of Permittee Date