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Home My Public Portal About5925 AGNES AVE_Plumbing__ 4KER'Sr:OMPENSATIONDECLARATION 6DPW 9l89 76A667A APPLICATION .FOR PLUMBING PERMIT 11 76A66 at I have a certificate of consent to self insure, ' ,,r... ate,of Worker's Compensation Insurance,:or a certified .,opy thereof(Sec. 3800 Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC,WORKS DIV. Prolic'No. Company L Certified copy is hereby furnished. k ` ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESS ,4 L' ! C_' department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY Date . Applicant 2 WATER CLOSET NEAREST CERTIFICATE OF.EXEMPTION FROM WORKERS' J BATH TUB CROSS ST. COMPENSATION INSURANCE ASSESSOR PAGE PARCEL ZtVP (This section need not be completed if the work involved by the ' SHOWER MAP BOOK lJJ a permit is for one hundred dollars($100)or less.) OWNER I certify that in the performance of the work for which this,permit LAVATORY / �a — L✓l�ni' is issued, I shall not employ any person in any manner so as toMAIL become subject to the Workers' Compensation Laws. SINK ADDRESS' # DISWASHER CITY TEL.N TczM C6 e i z l0`'J-76>L Date Applicant CLOTHES WASHER CONTRALTO NOTICE TO APPLICANT; If, after making this Certificate of C9 Exemption, you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labo'r' Code, you rTiust forthwith comply with such ADDRESS ,provisions or this permit shall be deemed revoked. rt LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. �" WATER HEATER TL? �f /T C f.,q �'9Ls 0- I'hereby affirm that I am licensed under provisions of Chapter 9 STATE LIC. 0 (commencing with Section 7000) of Division 3 of the Business and LICENSE NO. CLASS Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS # OUTLETS OVER DISTRICT NO. P SS Y a 5 PER SYSTEM 0 License Number Lie.Class ~ DATE"/f � 1FAL1 ATION W Contractor Date r i'•t- ❑ 1"ivvia4 I FFNAL rye_' fes �� I am exempt under Sec. r / / lam) _ �;`,j] jt},•�. B.&P.C.for this reason Plan check fee, Opp. 'T 5- Signature Date: PLUMBING'PERMIT ISSUING FEE.$ } �jlJ TOTAL 134 a 55 ❑ TOTAL;FEE �!Y HE 164,55 Plan check applicant CHANGE •}iS' SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name Fr�nlr _�N/ Cil r I hereby affirm that I am exempt from the Contractor's License Law 1; ort Ilowing reason (Section.7031.5,Business and Professions Address -,?.2,r 4CTIVC-S ;2'h/ r� Code): AM 24 City rrir C GIT (.,g Tel. No. ..d�9-9L4� i��.'4 _' 'j 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). , 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' 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 authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. ` SEE REVERSE FOR EXPLANATORY LANGUAGE 59-�r _ -Sionature_of_Permittee_� Date WORKERS COMPENSATION DECLARATION 76A667A hereby affirm that I have a certificate of consent to self ce e17 (z so) APPLICATION FOR PLUMBING PERMIT insure or a certificate of Workers Compensation Insurance or CITY OF �� TEMPLE CITY a certified copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGEL BUILDING AND SAFETY Policy No 201916Company SCIF 16fi570 � Certified copy is hereby furnished �� FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING }{ •Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM FEE ADDRESS 5925 Agnes ,i0en WATER CLOSET LOCALITY Temple Cit Datenen, ApplicantGeneralanstallatio NEAREST BATH TUB CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE SHOWER OWNER N. Florian (This section need not be completed if the work tnMAIL volved LAVATORY ADDRESS same d by the permit is for one hundred dollars ($100) or less) SINKCITv TEL Nt$$�j 0334 0 I certify that in the performance of the work for which this DISHWASHER tr permit is issued I shall not employ any person in any manner CONTRACTOR Generalt� so as to become subject to the Workers Compensation Laws CLOTHES WASHER h Date Applicant ADORE West Blvd. W SWIMMING POOL RECEPTOR NOTICE TO APPLICANT If after making this Certificate of CITiLOS Angeles TEL NO 7553_254 0- Exemption Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM - STATE LIC _ Compensation provisions of the Labor Code you must forth with comply with such provisions or this permit shall be 1 WATER HEATER 00 LICENSE NO CL SS G9 deemed revoked C D GAS SYSTEM OUTLETS LICENSED CONTRACTORS DECLARATION OUTLETS OVER 1 hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 19 (commencing with Section 7000) of Division 3 of the Busi DATE VALIDATION ness and Professions Code and my license is in full force and DATE b'� I ffect icense Number]-51839C36 FINAL 51839 Lic Class BY ontract.W_n_PrnV i n Date I am exempt from the licensing requirements as I am a Plan check fee licensed architect or a registered professional engineer ; PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051 Bus 0 iness and Professions Code) TOTAL FEE ,,c or Reg No Date Plan check applicant �'Z�SU 2 3 0 7 6 A HOME OWNER BUILDER DECLARATION Name o o'o 0 o 5 1 hereby affirm that I am exempt from the Contractors Address License Law for the following reason (Section 7031 5 Busi City Tel No ` ness and Professions Code) ClI as owner of the property am exclusively contracting 2 0 ° 1250 with licensed contractors to construct the project (Section 7044 Business and Professions Code) .' 00012505' CONSTRJCTION LENDING AGENCY 0 2,2 5—8 2 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 4 Lender s Address 1I certify that I have read this application and state that the (above information is correct I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing and hereby authorize representatives of this County to enter upon the above mentioned property for inspection purposes Signature of Permittee Date