HomeMy Public PortalAbout4831AGNES AVE_Plumbing (11) 1 �
�^ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A 'fl
nsu're"or a certificate of Workers Compensation Insurance CE 817(REV 10/81) RXZky City of Temple City
or a certified copy thereof(Sec 3800 Lob C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No 20191 Company SCIF 6975
Pol
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
® Certified copy is filed with the county building inspec ADDRESS 4831 Agnes Ave. 7t8
tion department NUMBER FIXTURE OR ITEM @ FEE
LOCALITY � Te 1@ City
Date 4-1-87 Applicant Genn
eral Istall. WATER CLOSET
NEAREST � �
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST La Rosa _Dr:`
COMPENSATION INSURANCE SHOWER OWNER Irwin Solomon
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less) LAVATORY ADDRESS 4831 Agnes Ave. #8
I certify that in the performance of the work for which this i
permit is issued`I shall not employ any person in any manner SINK CITY 81T8—'S00-4556
so as to become subject to the Workers Compensation Laws DISHWASHER
+ 01
CONTRACTOR General Installation Co.
Date Applicant CLOT SHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of 6558 West Blvd.
Exemption you should become subject to the Workers SWIMMINGIV&RECEPTOR
Compensation provisions of the Labor Code you must forth LAWN SPRINKLI EM CITY Los Angeles TEL N0753-2541
with comply with such provisions, or this permit shall be STATE LIC
deemed revoked 1 WATER HEATER 6 00 LICENSE NO 151839 CLASS C3
LICENSED CONTRACTORS DECLARATION , DISTRICT 1��� PROCES BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM TS ./X`(�// M
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and effect 5 PER SYSTEM ! r FINAL e:)11 ALIDATION
License Number 151839 Lic Class C36
14— FIN U
Contractor W.0_ Provin Date 4-55 BY
❑ I am exempt under Sec O
B 8P C for this reason W
Plan check fee ILI
Date PLUMBING PERMIT ISSUING FEE$ 10 .50 Z
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License Address L4 94.0 A
Law for the following reason (Section 7031 5 Business and # • • • • 5
Professions Code) City Tel No
❑ I as owner of the property will do the work and the f� e e 1 6,,5 0
structure is not intended or offered for sale (Section
7044 Business and Professions Code) loop • e e 16,5 0 5
CONSTRUCTION LENDING AGENCY Q a 7 -86
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 jaws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above mention e prop or inspection purposes
+ r SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of PermitGed Efate