HomeMy Public PortalAbout4846AGNES AVE_Plumbing (8) 4. WORKERS COMPENSATION DECLARATION s �
hereby affirm that I have a certificate of consent to self in 20 0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
Y CE 817 A
sure orJa certificate of Workers Compensation Insurance ora CE 817(REV 8/86)
cert fled copy thereof (Sec 3800 Lab tC ) I t
A a 1 COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No r Company 4 P y
Certified copy is hereby furnished` art 4 r #
J1. $ i FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
i❑ Certified%.copy is filed with the county building nspect on ADDRESS i Jt ! i a f r f I
department NUMBER _t FIXTURE OR ITEM @ FEE
7 J„ LOCALITY w y f J
Date t c� n r } t Applicant r ► )t t s€ WATER CLOSET(TOILET) NEAREST s 1 f tit 3r
+ 4 CERTIFICATE OF EXEMPTION FROM WORKERS i BATH TUB a p w d CROSS STr a t ^ a a
COMPENSATION INSURANCE Ii t SHOWER OWNER
'(This section need not be completed if the work involved by s + ' MAIL t e s x
the permit is for one hundred dollars($100)or less) 7 LAVATORY r a ADDRESS i t L} r t
I certify that in thel erformance of the work for wh ch this per
m t is issued I shall not employ any person in any manner so SINK CITY 4w It' i TEL NO a (
as to become subjecttto the Workers Compensat on Laws
4 J i ti t DISHWASHER S ,I CONTRACTOR
Date Applicant 1 CLOTHES WASHER " ADDRESS' t ~»
NOTICE TO APPLICANT If after making th s Certificate of Exr dSWIMMING POOL RECEPTOR if
emptron you should become subject to the Workers Compen CITY TEL NO
sation provisions of the Labor Code you must forthw th comp i LAWN SPRINKLER SYSTEM i t
f ly with such provis ons or this perm t shall be deemed revok x STATE ' LIC
ed F f WATER HEATER sK / t LICENSE NO r d J y CLASS
t
LICENSED CONTRACTORS'DECLARATION r r t DISTRICT NO ' PROCESSED BY
I he eby affirm that I am licensed under provis ons of Chapter t ( GAS SYSTEM OUTLETS
9(commencing with Sect on 7000)of Divis on 3 of the Business OUTLETS OVER d
and Professions Code'and my license is n full force and of 5 PER SYSTEM FINAL , VALIDATION— C
fect t a a iV DATE t a ' V
License Number "`J t 7 L c Class -J t W
F i `� ~ FINAL J
k {L
Contractor -W "k -.r I- Date f" �d 1` C BY
❑ Q-
1 am exempt under Sec r (. ' i r ✓ y Q
i B&P O C for this reason Plan check fee ► IL
r a f Date PLUMBING PERMIT ISSUING FEE$ ( a +
a
Signaturef Y + ;y TOTAL FEE 3 f t s
e SINGLE FAMILY r4t
t HOME OWNER BUILDER DECLARATION t Plan check appl cant
I hereby off rmrthat I am exempt from the Contractor s License Name
�r Law for the following reason (Sect on 7031 5 Business and
Professions Code) Addiess r 14
F-1I as owner of the p operty'w 11 do the4worrk and the City { Tel No t d L + gad a r
structure is not intended or offered for sale(Section 7044 d q s (k b 4r * 1
Bus ness and Profess ons Code) '
CONSTRUCTION7LENDING AGENCY + e, i >` ►i t v t F., 4
° I hereby affirm that there is a construction lending agency forr r i { f y Frayd s i
the performance of the work for wh ch this permit is issued r r f t t
(Sec 3097 C C )
Lender s Name
Lender s Address
x
I certify that I have pead th s applicat on and state that the
abo a information is correct I agree to comply with all County o ►'
ordinances and State jaws regulat ng Plumb ng and hereby y
outhori a representatives of this County to enter upont the &y
above mentioned grope ty for inspection purposes
+ E E
SEE REVERSE FOR EXPLANATORY LANGUAGE
S gnature of Pei — r e Date v t et t f t
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