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HomeMy Public PortalAbout4908AGNES AVE_Plumbing (4) {, r c'I have cerci DECLARATION t APPLICATION FOR PLUMBING PERMIT, t t " m of I have a certificate of consent to self 76A667A I insure' or a certificate of Workers Compensation Insurance CE 817(REV 10/81) ' or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LIDS ANGELES BUILDING AND SAFETY �"r Policy No Company Certified copy is herebyfurnished G p� AK/' D ❑ BUILDING ' FOR APPLICANT TO FILL IN(PRItIT OR TYPE) ADDRESS Al /Op PV6pt/�S Certified copy is filed with the county building inspec tion department r NUMBER FIXTURE OR ITEM r FEE LOCALITY a r t WATER CLOSET j Date Applicant NEARESTat r • CROSS ST j-Uw67� S i T CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB _ COMPENSATION INSURANCESHOWER r OWNER " aAiwN J (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less) LAVATORY _ ADDRESS !©� •v+ rT6�r�S I certify that in the performance of the work'for which this �f permit is issued I shall not employ any person in any manner ° SINK CITYqr_ n fi G TEL NO �r"Y'1 R + so as to become subject to the Workers Compensation Laws DISHWASHER j ' �*l CONTRACTOR, - r f Date Applicant '6 CLOTHES WASHER +s r ADDRESS NOTICE TO APPLICANT If after making this Certificate of _ Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR + Compensation provisions of the Labor Code you must forth CITY TEL NO LAWN SPRINKLER SYSTEM s with comply with such provisions or this permit shall be STATE LIC deemed revoked ' WATER HEATER M LICENSE NO CLASS r LICENSED CONTRACTORS DECLARATION m DISTRICT NO P SED BY ` I hereby affirm that I am licensed under provisions of Chapter 9 1 GAS SYSTEM OUTLETS W (commencing with Section 7000) of Division 3 of the BusinessOUTLETS OVER 5, d and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL VALIDAT N V DATE License Number Lrc Class dV q oC FINAL < O Contractor Date BY V CL I am exempt under Sec + H B&P C for this reason 1 ;11 3 7 4 A Z Date Plan check fee ~ PLUMBING PERMIT ISSUING FEE$ v # ° ° ° ° ° 5 Signature r TOTAL FEE > 1 • • 1 6,5 O a ` SINGLE FAMILY Plan check applicant Q • ° • 1 6 5 0 s v HOME OWNER BUILDER DECLARATION Name r Q 1 17-85 I hereby affirm that I am exempt from the Contractor s License Address Law for the following reason (Section 7031 5 Business and r , Professions Code) e t ' City_ r Tel No - t j I as owner of the property will do the work and the Pstructure is not intended or offered for'sole (Section lop. s { P 7044 Business and Professions Code) e N • , 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 ) .L r g , z r r + Lender s Name ' r -Lender sAddress 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 d authorize ypresentatives ni this County to enter upon the ' above tioned pr pe r i pe �n purposes + SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date i A +