HomeMy Public PortalAbout4818 AGNES AVE_Plumbing_6/11/1991_outlets - t
WORKERS COMPENSATION DECLARATION
ent )200026DPW4/874 APPLICATION FOR PLUMBING PERMIT
!Feby affirm that I have a certificate of consent to self in 76A667A
suI8 or a certificate of Workers Compensation Insurance ora CE 817(REV 8/86)
cert fled copy thereof (Sec 3'800 Lab rC ) � �J
113PolicyIINa '/29 70 Dmpany So1?,6ef J 41Rt s COUNTYrOF LOS ANGELES y DEPT OF PUBLIC WORKS
q ertifia i
ed copy is hereby furnished r,
k S apy y g P FOR APPLICANT TO FILL IN(PRINT OR TYPE) t BUILDING
Certified co is filed with the count buildin ins echon ADDRESS
d NUMBER + FIXTURE OR ITEW . FEE
department @
7 f p w a r LOCALITY + -
�,Date�" - ApplicantL r j� WATER CLOSET(TOILET) / a NEAREST /L �LC
P Y m,
6 CERTIFICATE OF EXEMPTIONtFROM WORKERS t w t BATH TUB CROSS ST
1• COMPENSATION INSURANCE + ` i OWNER �/ i
.4 v,e $ ti S I SHOWER E r 7- L - 4
(This section need not be completed if the work involved by _
the perm is for one hundred dollars($100)or less ) t r LAVATORY r -ADDRESS
I certify that in the"performance of the work for which this per P
mit istissued I shall not employ any person invany manner so SINK 6 _ CITY;7—� OLS C w�A TEL NO
as to become subject to the Workers Compensation Laws !
1 Toi r DISHWASHER F r
a CONTRACTOR t gr
Date �- r t lb `'Applicant "' I r CLOTHES WASHER x Y '
NOTICE TO APPLICANT If after making this Certificate of Ex rs - ADDRESS N L 1Q0�U
emption you should become subject`to the Workers Compen SWIMMING POOL RECEPTOR I a
sation fovisionslof the Labor Codet ou must forthwith com r CITY y14
�� TEL NO G S T��
P Y } P LAWN SPRINKLER SYSTEM G
ly with such provisions or this permit shall be deemed revok ' STATE LIC /� ��77
ed v a t� f WATER HEATER 4 LICENSE NO CLASS CLASS ` oLC�
LICENSED CONTRACTORS DECLARATION �t a DISTRI T NO ° P CESSED BY +
I hereby affirm that I am Iicensedtunder provisions of Chapter GAS SYSTEM OUTLETS o U a
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
„and`Professions Code andrmy license is in full force and of 5 PER SYSTEM FINAL / MALIDATION >'
I- t a b .§e ' DATE �! IL
L cense Number .5 �2 Lic Class P;zo f r N ' 7 �` V
,/ t �} �y v FINAL pip
Contractor AICAJ144D 7� l-Adate s -/t ! } y <." ' BY
a r >t s w H
I am exempt under Sec W
916r
t B&P Cafor this reason
v t xy
d .� Plan check fee
1 a x 9 Date $ 4"
z " t PLUMBING PERMIT ISSUING FEE
J. Its $
Signature ' a it t fsi° e
Ib t * ° TOTAL FEE
^ 4- SINGLE FAMILY ' + 3 w 4 + -Jj
b { HOME OWNER BUILDER DECLARATION Plan check applicant a r _
I hereby affirm that I am exempt from the Contractor s License Name +
Law for the following reason (Section 7031 5 Business''and )' L { iD ® ,[p
t ' Professions Code) a r N sAddress k a + _ a
e
x 1 as owner of the property will do the work and the x City , a € Tel No ¢ a Y
y structure is not intended or7offered for sale(Section 7044 UL
1 Business and Professions Code) c
4 CONSTRUCTION LENDING AGENCY t
I hereby affirm that there is a construction lending agency for � r a t
the performance of the work for which this permit is issued t .e a - } t >v r-1 J a W
(Sec'3097 Civ C ) t s + ' D 1 ~ tit A
S 4 ' f + t + dt k t 4is 4
R Lender s Name d ° '� r }
f a +
ik}
Lender i Address
t
I certify that I!Have read this application and state that the r x e a
above information is correci I agree to comply with all County t. Aa, e ti r
ordinances and State laws regulating Plumbing and hereby a k 'A loo.F s '^
author epresentatives of this County to enter upon the r t + t j * �r a „ i
abov me do ed pro erty for inspection purposes } w
t r` (� - t a rAr SEE REVERSE FOR EXPLANATORY LANGUAGE k r
IL '- ` e
Signature of Permittee Date's t a r ` 4