HomeMy Public PortalAbout5728 AGNES AVE_Plumbing__ WORKER '�
S'COMPENSATION DECLARATION
FOR PLUMBINGPERMIT
o
Jereaftu;r that I have a certificate of consent to self 76A667Ao
I tsure, or a certificate of Workers' Compensation,Insurance, CE 817(REV.10/81)
or a certified copy thereof (Sec.°3800, tab. C. COUNTY OF,LOS ANGELES BUILDING AND SAFETY
i Policy No. Company
Certified copy is hereby furnished, BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS at
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
r
Dale Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS SS. (J t
COMPENSATION INSURANCE SHOWER OWNER l t aert.Ty
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ an erson in an manner SINK g '^ CITY TEL. N
p Y Y'P Y � !' �D �!
so as to become subject to tl e orkers'Compensation Laws, DISHWASHER
pp _ CONTRACTOR '
n . A p CLOTHES WASHER
Date �4/ Applicanf ADDRESS
NOTI E TO APPLICANT`. If, after making this Certificate of '
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
P Y I 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. P OCESSED 8Y
I hereby affirm that I am Licensed under provisions of Chapter
GAS.SYSTEM OUTLETS
(Commencing with Section 7000) of Division 3 of the Business OUT OVER
and Professions Code,and my license is in full force and effect._ 5 PER SYSTEM m FINAL' n % %
DATE" r o
Jv� !!. 'LIDATION
License Number Lic. Class
FI L l
{_ Contractor - Date - B
i t
❑ I am exempt;under Sec. —
C �
I B.BP.C. for this reason
Plan check fee �
Date: _ $ � e
PLUMBING PERMIT ISSUING FEE
Signature -
. TOTAL FEE SO
Plan check applicant` 3 3 9.3 A
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name # 0 0 0 0 0 5
I herebffirm that I am exempt from,the Contractor's License Address ( o -34,50
V1,
- r the following, reason 'Section 7031.5, Business and
ions Code): City Tel'. No. � 0
0 o a
as owner of th,e property., will do the work and the
structure is not intended,or- offered for sale (Section ( ""
4 7044, Business and Professions Code).
•+ CONSTRUCTION.LENDING AGENCY
I hereby affirm that there is a' constructionlending 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 1, 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 representatives of this County to enter upoq the
above- tione damperty for'inspection purposes.
p SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date