HomeMy Public PortalAbout5806 AGNES AVE_Plumbing__ y rRS'COMPENSATION DECLARATION P LIGATION FOR PLUMBING PERMIT
I hereL_, 1h that I have a certificote4of conseni tr, self 76A667A I
insure, or Artificate 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. BUILDING
AA /p�
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) i ADDRESS 1 dB / 6�i � a A
Certified copy is filed with the county building inspec-
06tion department. NUMBER FIXTURE OR.ITEM @ FEE - Y r
LOCALITY
WATER CLOSET r
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUBI i CROSS ST. \ r
COMPENSATION INSURANCE SHOWER �� OWNER 11 r
(This section need not be completed if the work involved by -
the permit is for one hundred dollars ($100)or less.) MAIL
LAVATORY '' ADDRESS
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK CITY TEL. NO. - a
so as to become subject to the Workers Compensation Laws. DISHWASHER Irn�
} CONTRACTOR
t zZ- '
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making•th s Certificate of —'
Exemption, you should become subject to the Workers' SWIMMING POOL-RECEPTOR
CITY 'TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM i—. A
with comply with such provisions or this permit shall be STATEr�99 (Qy� LIC.
deemed revoked. WATER HEATER -- LICENSE NO. � eL li CLASS —d
LICENSED CONTRACTORS DECLARATION 6' DISTRICT NO. OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS d£I
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM 1 96
FINAL %? VALID ION' 96
DAT
License NumberLic. Class j
FINAL- l:
Contractor 1 Date 'O"" �Y �' ; BY
❑ .'1 am exempt under Sec.
B.&P.C. for this reason 0 9 3.6 A
Plan check fee i # 0 0 0 0 0
Date: PLUMBING PERMIT ISSUING FEE$ e!
Signature 0 - 5850
TOTAL FEE
Plan check applicant i
SINGLE FAMILY 0005a'506
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License j 1019-84
Law for the following reason (Section 7031.5, Business and Address
Professions.Code): City Tel. No. )
❑ I, as owner of the property, will do the work and the I
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
j 1
I hereby affirm that.there is a construction lending agency for }
the performance of the work for which this permit is issued It
(Sec. 3097, Civ. C.).
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 I
authorize representatives of this County to enter upon the
above-mentioned propert for inspection purposes. 1
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of ermit a Date j i