HomeMy Public PortalAbout6327 AGNES AVE_Plumbing__ WORKERS COMPENSATION DECLARA;tiQN APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of-94seat 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
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Policy No Company
Certified copy is hereby furnished
ElM1FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 3 7 r t/yam
Certified copy is filed with the county building inspec ADDRESS ���•t�
tion department NUMBER FIXTURE OR ITEM n FEE LOCALITY �e
Date Applicant WATER CLOSET �� NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST c✓i,�
COMPENSATION INSURANCE ! SHOWER OWNER -/
/7007
(This section need not be completed if the work involved by
the permit is for one hundred dollars $100 or less �� MAIL
p ( ) ) LAVATORY ADDRESS d
I certify that in the performance of the work for which this 7
permit is issued I shall not employ any person in any manner SINK CITY S7 �,� TEL 7
so as to become subject to the Workers Compensation Laws DISHWASHER
,L� - CONTRACTOR C
Date 1a -(3�- pphcant r/C1�A-'%/ //� fi� CLOTHES WASHER
NOTICE TO APPLICANT If after making this Certificate of ADDRESS
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM CITYL6�� TEL NO -Z30
with comply with such provisions or this permit shall be STATE {� LIC '
deemed revoked ' WATER HEATER ,r.. LICENSE NO CT Cv .T-fa CLASS -i
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 l GAS SYSTEM _ Z-OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER (/
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL VALIDATION U
}�icense Number 3 1 tPC �1-4 Lic Class DATE ")� . �� U
FIN
K (��c�LwO►n-- '-J25.1 0 (e /0- 3 4-3 BY AL t� Ucontractor 5 9 0 A w
❑ I am exempt under Sec
B &P C for this reason o to 0 0 0 5
Date
Plan check fee 110. 2 - 4050
PLUMBING PERMIT ISSUING FEE$
Signature ° ° ° 4 0 5 0 cs.
TOTAL FEE �
Plan check applicant
X012-83
SINGLE FAMILY
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) I 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
Lenders 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
`
above propertyofns, ecti purposes r
(///f ZT SEE REVERSE FOR EXPLANATORY LANGUAGE
ISignature�of Permittee Date