HomeMy Public PortalAbout5813 AGNES AVE_Plumbing_11/16/1987_ ` WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
L fslfe' jv ffirrrPthat I have a certificate of consent to self m 20 0026 DPW 4/87
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stere or a certificate of Workers Compensation Insurance ora CE CE 817 817(REV 8/86) -
cerTifiiied copy thereof (Sec 3800 Lab C )
' COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No Company
Certified copy is hereby furnished
1 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
t w WATER CLOSET(TOILET)
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Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS f BATH TUB CROSS ST
r COMPENSATION INSURANCE SHOWER Del OWNER
t(This section need not be completed if the work involved by UU MAIL 3 1
the permit is for one hundred dollars ($100) or less ) LAVATORY ADDRESS57S 1
I certify that in the performance of the work for which this per SINK ^(�`''}/
mit is issued I shall not employ any p rson in any ner so CITYea_ r_zj EL NO O`a J
as to become subject tc the Workers ensati n ws DISHWASHER
1 .. CONTRACTOR
Date°Applicant CLOTHES WASHER ADDRESS y
NOTICE T APP ICANT If after making this Certificate of Ex SWIMMING POOL RECEPTOR
emption you should become subject to the Workers Compen CITY TEL NO
sation provisions of the Labor Code you must forthwith comp LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok STATE LIC
ed ( WATER HEATER v.l LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESS BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER U(J
and Professions Code and my license is in full force and of 5 PER SYSTEM FINAL ✓/� ALIDATION d
fect DATE C3/7
License Number Lic Class O
FI V
t i Q
Contractor Date B 0
H
I am exempt under Sec U
W
B 8P C for this reason ay
Plan check fee z
Date PLUMBING PERMIT ISSUING FEE$ S
Signature TOTAL FEE ;98365A
e
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Plan check applicant # 005
j hereby affirm that I am exempt from the Contractor s License Name I - - 7050
Law for the following reason (Section 7031 5 Business and
Professions Code) Address 0 70505
I as owner of the property will do the work and the City Tel No ( 1 16-87
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structure is not intended or offered for sale(Section 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 b
3 �
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 tate laws regulating Plumbing and hereby
aut rize repre ntotives of this County to enter upon the
abo ention proper for inspection p rpo es
' SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign re of Permittee I D to