HomeMy Public PortalAbout5943 AGNES AVE_Plumbing__ s
�n t COMPENSATIONDECLARATION APPLICATION 'FOR PLUMBING PERMIT
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tl re a firm at 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 NG
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDI ^9/1 /
Certified copy is filed with the coup bus ing inspec ADDRESS 7 • -/`Q
NUMBER FIXTURE OR ITEM FEE LOCALITY
tion departmrreQQnt �
Date ���0 ��'Applicani 2 WATER CLOSET — NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS 2 BATH TUB _. CROSS ST L S (� S
COMPENSATION INSURANCE SHOWER OWNER Bintis
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less ) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY TEL NO
so as to become subject to the Workers Compensation Laws
DISHWASHER CONTRACTOR c
Date , Applicant CLOTHES WASHER
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NOTICE TO APPLICANT If after making this Certificate of ADDRESSJQq JAI2M 1_-T 0
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM I 1 CITY 1l�/1 wRoV iA, TEL NO /
D
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO 2 CLASS C-3
LICENSED CONTRACTORS DECLARATION DISTRICT NOOCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER >_
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINALVALIDATION CL
C DATE
License Number � Lic Class U
1 SH
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Contractor`PVT Sa *W Date 2——2 �v
❑ I am exempt under SecLU
B&P C for this reason rA
Non check fee Z
Date PlPLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License Address
Law for the following reason (Section 7031 5 Business and
Professions Code) City Tel No
❑ 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 r 2 4 0 9 0 A
I hereby affirm that there is a construction lending agency for # 0 0 0 0 0 5
the performance of the work for which this permit is issued
(Sec 3097 Civ C )
7 6 5,0
Lender s Name 0 0076503:° 7650
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Lender s Address 0224
—86
1 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
authors e repr sen atives of this County to enter upon the
above enti e roperty for inspection purposes
j(J SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date