HomeMy Public PortalAbout6322 AGNES AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in- 76A667APW 4/90
sure,ov b certificate of Workers'Compensation Insurance,or a
c6rtifieci copthereof (Sec. 3800, Lab. C.)
502524 REPUBLIC TNn •2\,ZTY COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
❑ Certified copy is hereby furnished., BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) 6322 AGNES
Certified copy is filed with the county building inspection ADDRESS
department. y/)�/�,� NUMBER FIXTURE OR ITEM @ FEE LOCALITY
/ /Lw�wWATER CLOSET(TOILET)
—ApplicantA, TEMPLE CITY, CA
Date 6/24/95 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER PAUL PIERCE
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS P.O. BOX 1437
I certify that in the performance of the work for which this per- SINK TEMPLE CITY CA 91780 285--1683
mit is issued, I shall not employ any person in any manner so CITY TEL. NO.
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR FRANK MARRONE & SONS, INC.
Date Applicant. CLOTHES WASHER - 9860 LOWER AZUSA ROAD
NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS
tion,you should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR
em
p y I Compen.- EL MONTE, CA 91731 TEL. No. 444-2548
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.71
ed. WATER HEATER ` LICENSE NO. 397884 CLASS:C/36 C/16
LICENSED CONTRACTORS DECLARATION !J GAS SYSTEM OUTLETS DISTRICT NO. PRQCESSED'8Y
f
I hereby affirm that I am licensed under provisions of Chapter ��J � ��� y�����' ' '-: •li-.
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINALjM'
fect. VALIDATIOFI,'"
/ HOSE BIB ` DATE l.q�
License Number '1978Ra Lic. Classy/36 2/16
12/31/95 FINAL -''• ww
CcIhsrcDJARRQD E & �nNS, TN(' Date BY
1 am exempt under Sec. U
B.BP.C. for this reason =' ).'_.'–'JUL,` 1 �
Plan check fee . '`a
Date: PLUMBING PERMIT ISSUING FEE$ '`'i' `;
Signature
TOTAL FEE l d
SINGLE FAMILY
HOME 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
Professions Code): Address
I, as owner of the property, will do the work and the City Tel. No.
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
authorize representatives of this County to enter upon the
a ve e Toned property for inspection purposes.
�4 `s SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date