HomeMy Public PortalAbout5758 AGNES AVE_Plumbing__ ION
Nm that I'S have
aceSATate of consent to 76A666DPW9/89 APPLICATION FOR PLUMBING PERMIT LI
76A667A
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
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 •"'r�
LOCALITY
Date Applicant WATER CLOSET Com'
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST q
BATH TUB CROSS ST. (�'dr�/vltivl
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) OWNER
LAVATORY
1 certify that in the performance of the work for whic permit ' L
is issued, I shall not employ aMAIL
��d �&✓
ny person ' an nn so as to SINK
become subject to the Workers' Compen do a ADDRES
DISWASHER CITY
- 2 Date 4;38— Y / CLOTHES WASHER
CONTRACTOR � � j��
NOTICE TO APPLICANT: If, after making W16,er ificate of c_ iY
Exemption,you should become subject to the Wo e 'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthw th omply with such ADDRESpnea
provisions or this permit shall be deemed revo LAWN SPRINKLER SYSTEM lll///
LICENSED CONTRACTORS DECLARATION CITyA1W11-Ja""
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
(commencing with Section 7000) of Division 3 of the Business and STATE �f��2�2 LIC. Q
Professions Cade, and my license is in full force and effect.
GAS SYSTEM OUTLETS LICENSE NO.o� 7J� CLASS " Q
OUTLETS OVER DISTRICT NO. PROCESSED BY Cc/� / 5 PER SYSTEM O "=f o
License Numb6p=l / Lic.CIas _ c51 Q U
DATE��/,/! / / FINAL VALIDATION LLI
Contractof/ ��y� L�0&� (� Q Z. )7•- � a
Date
El FINAL Z
I am exempt under Sec. BY /
BAP.C.for this reason
Date: Plan check fee ,
Signature
PLUMBING PERMIT ISSUING FEE$ LfQ
❑ TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name ~_.__ f
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Address
Code):
EJ 1,
Tel. No. t. t 4 J_ �, Ey
ra
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I, as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). ' _,•••. -. e-.
CONSTRUCTION LENDING AGENCY ,
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.) _ ...+fa t
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 law. gulat' lumbing, and hereby authorize
representati s of ty to enter upon the above-mentioned
property f r in urposes. j SEE REVERSE FOR EXPLANATORY LANGUAGE
/Z
Signature of PerWriftee Date