HomeMy Public PortalAbout5742 AGNES AVE_Plumbing__ c� W JJ2KERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
j I herel�> ffirmv that I have'a certificate of consent to self 76A667A
'insure; or, iX cer.,ificote of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM
@ FEE LOCALITY
WATER CLOSET v
Date Applicant BATH TUB O CROSS NEARESTT.00&,W1W AO.'Ci
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OWNER �r
(This section need not be completed if the work involved by SHOWER QQ Pio�liC, /�_
the permit is for one hundred dollars $100 or less. MAIL �y L
P ( J J LAVATORY OL/ ADDRESS �J / �2'
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY ?' !_ e-"7— TEL. NO.IK 7 f rf
so as to become subject to the Workers Compensation Laws. DISHWASHER / �r v-�
�1 CONTRACTOR ��s��pf
Date y �� Applicant / CLOTHES WASHER t��/ ADDRESS 9/
NOTICE TO APPLICANT: If, after makin this Certificate of P/ �r gWok
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. LASS
LICENSED CONTRACTORS DECLARATION DISTTRI NO, OCES�SED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM / OUTLETS Q �%'
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER (/
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FI I
VALI T yo
License Number Lic. Class awl
O
F L (A
Contractor Date
I am exempt under Sec.
O
B.BP.C. for this reason W
Plan check fee L-
Date: PLUMBING PERMIT ISSUING FEE$
-no
Signature .
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address 1.
Law for the following reason (Section 7031.5, Business and tr
Professions Code): City Tel. No. v
(r11 I, as owner of the property, will do the work and the c 5 2 9 0
structure is not intended or offered for sale (Section \ Uf o,o o•o.o 5
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I ° aaG50
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued o 0 o 0, 5 0 5
v
(Sec. 3097, Civ. C.).
08,21 y86
Lender's Name ;2 5 2 9,:1 A
Lender's Address # 0 0 0 0 0 5
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County °.° 4 Q 5 0
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the 4 Q 5 0 5above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signaturd7of Permittee D to