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Home My Public Portal About6042 AGNES AVE_Plumbing_8/12/1993_ WORKER'S COMPENSATION DECLARATION 6DPW 9/89 APPLICATION FOR PLUMBING PERMIT 76A66 I Fjereby affjrm-1h'0 I have a certificate of consent to self insure, 76A667A or a certiflcate'of WorKer's Compensation Insurance,or a ertified copy thefeof�S 0 b C.) ` COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No/_/4 r Compan Certified copy is hereby furnished. 1^` FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building ADDRESS department NUMBER FIXTURE OR ITEM FEE LOCALITY /p Dal Applicani/A WATER CLOSET NEAREST C� CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. i BATH TUB COMPENSATION INSURANC ASSESSOR 7 (This section need not be completed if the involved by the SHOWER MAP BOOK PAGF�/� PARCEU*1 permit is for one hundred dollars($100)or less.) OWNER o f� 1 certify that in the performance of the work for which this permit LAVATORY is issued, I shall not employ any person in any mann so as to SINK MAIL become subject to the Workers'Compensation L ADDRES DISWASHER CITYop, TEL.NO. c Date Appli _ CLOTHES WASHER NOTICE TO APPLICA f, after making this Certificate of CONTRACTOR SB Exempti�tabor ecome subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisioCode, you must forthwith comply with such ADprovisiomit shall bedeemed revoked. LAWN SPRINKLER SYSTEM �j�y'�ED CONTRACTORS DECLARATION IT EL. 1 f� I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000) of Division 3 of the Business and GAS SYSTEM OUTLETS STATE LICENSE NO. L[cS j �^ CC. S (� Professions Code,and my license is in full force and effect. �� OUTLETS OVER DISTRICT NO. PROCESSED BY 5 PER SYSTEM '�' ,• Q License Number `� • Lic.Class _ FINAL `t'16c�_}(U W -',Z �. DATE V�CC' ATION IL Contractor D t ` o FINAL //�1 TOTAI : (n I am exempt under Sec. ll�(�(iWv _ B.&P.C.for this reason CHECK Plan check fee CH l.__ Date: , t•ti�t�t`:.i� Signature PLUMBING PERMIT ISSUING FEE$ TOTAL FEE Plan check applicant SINGLE MILY '("!?�• i HOME OWNER-BUILDER DECLARATION Name L AM I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address 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 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 Poo- and State laws reguIati g umbing, and hereby authorize representatives of tpjs. ter upon the above-mentioned property for in ect' purpos SEE REVERSE FOR EXPLANATORY LANGUAGE Signatur O Ittee Date