HomeMy Public PortalAbout5746 AGNES AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION 20-0026 DPW 4/87
APPLICATION FOR PLUMBING PERMIT
I hereby,"affi,m that I have a certificate of consent to self in= 76A667A'
Byrd!ora certificate of Workers'Compensation Insurance,or a. CE 817(REV. 8/86)
partified:copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
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 inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY . a ,{fir✓,
WATER CLOSET(TOILET).,, 0 �/'� av
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 0 0 CROSS ST. Q L
COMPENSATION INSURANCE Y-'
OWNER tnrC f) >✓
2 SHOWER O ICsV
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100) or less.) 3 LAVATORY ADDRESS
I certify that in the performance of the work for which this per- `
SINK
mit is issued, Y TEL. NO. �.(L l'
shrill not employ any person in any mannCIT
manner so c1 lll�c�
as,to beco e subject to the Worker mpensa n aws. DISHWASHER
{/ CONTRACTOR
Date 1 App licaf�t �' CLOTHES WASHER
NOTICE'T6 APPLICANT: If, after maki g this Certifi ate of Ex ADDRESS
em tion,you should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR
P Y I P Q CITY TEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
Iy with such provisions-or this permit shall be deemed revok- STATE UC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATIONDI$TRIUY OCE D Y
I hereby affirm that I am licensed under provisionsrof Chap?er GAS SYSTEM OUTLETS (o�Sf[(
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER 9
fed Professions Code; and my license is in full force and ef- 5 PER.SYSTEM FINAL. / VALIDATION
. DATE � 26'�J O
License Number Lic. Class 7 Q
FINAL
Contractor Date BY / O
I•am exempt under Sec. UJ
B.&R.C. for this reason ► g
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE $
Signature
TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATIONPlan check'applicant
3*1070ticll
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and L'TEMS
Professions Code): Address
I.IAL - 0
6 50
I, as owner of the property, will do the work and the City Tel. No. t pry
structure is not intendCHECK or offered for sale(Section 7044, .HECK �.Ct',.1` ,_0
Business and Professions Code).
Poo. oCHANGE
):Iti.
�-
CONSTRUCTION LENDING AGENCY
I hereby affirmthat there is a construction lending agency for
the performance of the work-for which,this permit is issued 0000-00011 11/
(Sec.3097, Civ. C.). -71
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 laws regulating Plumbing; and hereby
authorize representatives of this County to enter upon the
o e-mentionediprop rty foe''inspection purp ses. "
-� SEE REVERSE FOR EXPLANATORY LANGUAGE '
Sig ature of Permitt Date