HomeMy Public PortalAbout4849AGNES AVE_Plumbing (2) t
I
WORKERS COMPENSATION DECLARATION Ike 20 0026 DPW 4/87 —APPLICATION FOR PLUMBING PERMIT
�
I hereby taff rm that I have aH certificate of consent to self in 76A667A ' S
SI e c r a certificate of Workers Compensation Insurance or a CE 817(REV 8/86) S � 't
c tifie�co y th2e�reyo7(Sec 3800 Lab C ) COUNTY OF LOS ANGELES r DEPT OF PUBLIC WORKS t A
Poli I Jr 3 /7 Company fziT,+Tz:r PUMP r ro t+
� Certified copy is hereby furn shed
td BUILDING
t FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS /tIt ✓�(/� j
Certified copy s f led w th the county build ng nspection
depa tment r 6 NUMBER FIXTURE OR ITEM Q FEE LOCALITY
2 Y WATER CLOSET(TOILET) 4 s t s
Date / Applicant NEAREST
i /ems
CERTIFICATE OF EXEMPTION FR M R ERS y BATH TUB CROSS ST r J
t COMPENSATION INSURANCt SHOWERr e OWNER i f s
K f
(This section need not be completed if the work involved byMAIL dr/r
the permit is fc rlone hundred dollars ($100)or less) LAVATORY f 1 ADDRESS 4
1 certify that in the performance of the work for which this per s r / .0 s
mit is ssued I shall not employ any person in any manne so SINK 4+ CITY TI-Mm
AS /� TEL NO
as to become subject to the Workers Compensat on Laws DISHWHER w C- tJ�i I
4 4 CONTRACTOR
t �Tl
Date Appl cant CLOTHES WASHER t
NOTICE TO APPLICANT If afte mak ng th s Cert f cate of Ex / _ ADDRESS"
you should become subject to the Workers Com en I- 7
em tion b SWIMMING POOL RECEPTOR
P Y I P t CITY Gb �(y TEL NO
64 �p t
sat on provisions of the Labor Code you must forthwith comp ». LAWN SPRINKLER SYSTEM 9
ly with such provisions4or th s permit sholltbe deemed revok STATE v Q LIC t
ed 1 { r ` 't d t WATER HEATER LICENSE NO Lt9 CLASS
3 !LICENSED CONTRACTORS DECLARATION { `r DISTRICT NO:57 + PROCESSED BY
Iihe eby off rm that I am I censed under pro s ons of Chapter e A GAS SYSTEM OUTLETS m a
91(commenc ng w th Section 7000)of D v s on 3 of the Bus ness M OUTLETS OVER 7,:), S
and Profess ons Code and my I cerise Zse is n full force and of 5 PER SYSTEM r f t N FINA lot A'S { ALIDATION ;r O
a fect t Q s DATE 7o vJ/
License Number 1F r3 L c Class C_7'0 V
``__ d FINAL ��l ` 4 i 9C
Contracto4lk�fl./� U�7J✓Gl_ Date s , BY �'�`� O
' O
r I am exempt under Sec
B 8P C+for this reason
►' Plan check fee m ® z
4 4 Date t PLUMBING PERMIT ISSUING FEE$
s
S gnature - TOTAL FEE k r S + ~
SINGLE FAMILY r Plan check'�a licant a y 3307 ib 9i'I
r HOME OWNER BUILDER DECLARATION s FP t ��
I hereby affirm that I am a empt from the Contractor s License Name r A 1 ITEMS
Low for the follow ng reason (Section 7031 5 Business and o '
Professions Code) J Address 4N �� sr € + TUTAL J.6 se,50
I i`as ownerlof the property will do the work and the C ty Tel No } CHECK y 15 90 a
stucture s not ntended or offered for sale(Sect on 7044 b „ yt * I OL
Business and Profess ons Code) a 4 r h' rl�tlrVc ti^
a
+ f CONSTRUCTION LENDING AGENCY
I hereby off rm that there s a construction lend ng agency for ° ! r 3 a -0001 9/13/39
the performance of the work for which th s permit is ssued n t 4`
(Sec 3097 CIV C ) 4 t s 96761 ] AM 9 M
t �
Lende s Name t $ t B
Lender s Address 's
I certify that I ho a read th s appl cation and state that the s c }
above information is correct I agree to comply w th all County x t x i + s ( ® ;
"r
ord nonces and State laws regulat ng Plumbing and hereby
authorize representat ves of this County to enter upon the
above mentioned roperty for inspection purposes t y
, 7-1)$Q SEE REVERSE FOR EXPLANATORY LANGUAGE
S gnatuV of P r ttee r Date
4. t