HomeMy Public PortalAbout5822 AGNES AVE_Plumbing__ WORKERS COMPENSATION DECLARATION - 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)
ora certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES ` BUILDING AND SAFETY
Policy No ' CompanyS�5U Rijn[..!5 Dr"i C WEST'
Certified copy is hereby furnished BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county building inspec
tion department NUMBER FIXTURE OR ITEM 0 FEE
LOCALITY
WATER CLOSET
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE OWNER
(This section need not be completed of the work involved by SHOWER
the permit is for one hundred dollars $100 or less MAIL
P ( � � LAVATORY ADDRESS fh
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 Mf TEL NO
so as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR r
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth CITY TEL NO 5 ��
LAWN SPRINKLER SYSTEM i4dalla-AX L-411
wi,h comply with such provisions or this permit shall be STATE LIC
Sfl $ deemed revoked WATER HEATER LICENSE NO 7 CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
da�I-ommencing with Section 7000) of Division 3 of the Business OUTLETS OVER 9,
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL VALIDATION CL G b -Z 7''
License Number�37d5,S f Lic Class ACJ DATE U
FINAL
Contractor(agn Far_n6y Date BY dr 0
1 am exempt under Sec 2
B &P C for this reason
Plan check fee �r?� Z
Date
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION Name 240 1 4 A
I hereby affirm that I am exempt from the Contractor s License Address 0 0 0 0 0
Law for the following reason (Section 7031 5 Business and
Professions Code) City Tel No❑ Z o - 3050
1 as owner of the property will do the work and the
structure is not intended or offered for sale (Section , o 0 0 3 0 5 0 czi
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY 0 7 2 7-837
1 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 mentio eclproperty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
.. ?oZ7-Y3
Signature of Termittee Date