HomeMy Public PortalAbout5812 AGNES AVE_Plumbing__ WORKERS COMPENSATION DECLARATION A r I `� APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure or a certificate 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
F-1Certified
APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the county building inspec ADDRESS
tion department NUMBER FIXTURE OR ITEM @ FEE
r LOCALITY
Date Appli4ant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
r
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER �U
the permit is for one hundred dollars $100 or less MAIL
P ( ) LAVATORY ADDRESS /
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY �^ TEL NO
so as to become subject to the Workers Compensation Laws DISHWASHER
�f � � CONTRACTOR 1 �
ate V 31 Applicant CLOTHES WASHER
OTICE TO APPLICANT If after making this Certificate of ADDRESS
��``xemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth CITY TEL NO
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM
deemed revoked STATE LIC
WATER HEATER ./" S LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION 7C /17 1DISTRICT NO OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER >'
and Professions Code and my license is in full force and effect 5 PER SYSTEM4— d
DATEL VALIDATION u
License Number Lic Class
FINAL O
Contractor Date BY ~
❑ V
I am exempt under Sec ILLU
N
B 8P C for this reason
Plan check fee
Date
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEEVA -1-391 2A
Plan check applicant 5
SINGLE FAMILY � o o a o-o
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License 2 ° o46,50
Law for the following reason (Section 7031 5 Business and Address
Professions Code) City Tel No o L° o [f b 5 U
❑ I as owner of the property will do the work and the 09 31 —84
structure is not intended or offered for sale (Section 00,7044 Business and Professions Code)
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 )
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 jaws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above mentioned property for inspection purposes
,. SEE REVERSE FOR EXPLANATORY LANGUAGE
41_t
Signature of Permittee Date