HomeMy Public PortalAbout6006 AGNES AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION 'APPLICATION FOR• PLUMBING PERMIT
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I hereby, affirm 20-0026 DPW 4/90 that I have a certificate of consent to self in- 76A667A
sure.,or a certificate of Workers'Compensation Insurance,or a
olio iC�d:sopy thereof(Sec. 3800, Lab. C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING /I
' Certified copy is filed with the county building inspection ADDRESS �p06
deportment. FEE et/I�S
NUMBER FIXTURE OR ITEM LOCALITY c
@
r WATER CLOSET(TOILET) f
Date —Applicant NEAREST -
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST.
COMPENSATION INSURANCE 1 SHOWER OWNER
(Thissection need not be completed if the work involved by
MAIL
the permit is For one hundred dollars($100)or less.) ' � LAVATORY - ADDRESS
I'certify that in the performance of the work for which this per- SINK CITY TEL. NO.
mit is issued, I shall not employ person in any manner so
as to become subject to the Work ' Compensation Laws.
DISHWASHER �/� � /•A�,i�/
CONTRACTOR
Date 1-7-G -7C Applicant CLOTHES WASHER ADDRESS I 5 �,q1L /�1ri�ODw �ij
NOTICE TO APPLICANT: If, aft mak' g this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become s bjec to the Workers'Compen- CITY TEL. NO. 55:1-g 74
141
sation provisions of the Labor C , you must forthwith comp- LAWN SPRINKLER SYSTEMS 44-a7A
ly with such provisions or this permit shall.be deemed revok= STATE .,,/ LIC. q>
ed. WATER HEATER LICENSE NO. S CLASS 1a
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY
I hereby affirm that I am licensed under provisions of.Chapter GAS SYSTEM OUTLETS e�f
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL �Z-C� VALIDATION
fect. HOSE BIB DATE
License Number '527? S7 Lic. Class
f P FINAL y
Contractor<<I!M 2s�1pate `�`� BY •�• e s
I am exempt under Sec. �O 3303 123. UV
B.&P.C. for this reason 1 ITEMS
�
Plan check fee _
Date: PLUMBING PERMIT ISSUING FEE$ � TrITAL -9 23 @ 90U)
Signature TOTAL FEE C CHECK 123.90
SINGLE FAMILY CHANGE .00HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and E�I�001 1/26/96
Professions Code): Address
El I, as owner of the property, will do the.work and the City Tel. No. 4473 1 AM10o21
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 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
au orize representatives of this County to enter upon the
abo e-mentio d roperty f insp tion purposes. -
1_ _ SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign lure of Permitt a Date.