HomeMy Public PortalAbout4910AGNES AVE_Plumbing (13) WORKERS COMPENSATION DECLARATION CIE 817 APPLICATION FOR PLUMBING PERMIT-'
I hereby affirm that I have a certificate of consent to self cE e» z eol
insure or a c�*Ilficate of Workers Compensation Insurance or
a cer+y fied coi"thereof(Sec 3800 Lab C)
e r, COUNTY OF LOS ANGEL BUILDING AND SAFETY
Policy No Company x , '
R l d
Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ,
ADDRESS
NUMBER FIXTURE OR ITEM A FEE (7
A 17
Certified copy is Bled with the county building inspection e
department , ` t t' WATER CLOSET " LOCALITYA-M 00 f C/ �L e +
rDate Applicant NEAREST
c BATH TUB r CROSS ST f/il° t
CERTIFICATE OF EXEMPTION,FROM WORKERS c "r
d ' COMPENSATION INSURANCE , SHOWER OWNER) r Al Q u SPa M
(This section need not be completed if the work involved LAVATORY ADDRESS 0CL
by the permit is for one hundred dollars ($100) or less) _ O
S-
Y SINK CITY n P r TEL NO a3a 0 s
I certify that in the performance of the work for which this DISHWASHER ` CONTRAC R IL
permit is issued I shall not employ any erson in any manner y O
so as to eco subject to the rker Compe ti Laws CLOTHES WASHER , , r H
r tr ADDRESS , Q
r Date Applicant SWIMMING POOL RECEPTOR x /, W
NOTIC TO APPLICANT If ter making this Certificate of� CITY r� TEL NO,?e,',2— a
rn
Exemption you should bec a sublect to the Workers LAWN SPRINKLER SYSTEM STATE LIC Z
Compensation provisions of the Labor Code you must forth WATER HEATER LICENSE NO CLA
with comply with such provisions or this permit Wall be
deemed revoked DISTRICT N + R SSED
" GAS SYSTEM OUTLETS
LICENSED CONTRACTORS DECLARATION OUTLETS OVER g; G
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM i
9.(commen cm&with Section 7000)of Division 3 of the Busi - FINAL
ness and Professions Code and my license is in full force and DATE _ VALIDATION
effect r
License Number d d 73 93 Lic Class C J J Y FINAL
Contractor Date eZ
—FJI am exempt from the licensing requirements as I am`a Plan check fee "
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ O
acting in my professional capacity (Section 7051 Bus r
mess and Professions Code) +` ` - �TOTAL FEE
+ r
Lic or Reg No Date Plan check applicant
HOME OWNER BUILDER DECLARATION Name r4 .
I hereby affirm that I am exempt from the Contractors /address - , ' :93820A
License Law for the following reason (Section 7031 5 Busi City , Tel No '
ness and Professions Code) ' ' " # • • • • • 5 + I
I as owner of the property am exclusively contracting y "? J
with licensed contractors to construct the project , 2 • • 1t 2 5 0
(Section 7044 Business and Professions Code) , + «' r i
+ r . . . 1250�( r
CONSTRUCTION LENDING AGENCY + _ '
I hereby affirm that there is a construction lending agency 0 a,2 8—8 2
for the performance of the.work for which this permit is +
issued(Sec 3097 Civ C)" •1 r r a , i
Lender s Name +
Lender s Address i
Y
I certify that I have read this application and state that the + ,
above information is correct I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances nd State laws regulating Plumbing and hereby
authorize a resentatives of this County to enter upon the
above me t ned property for inspection purposes >
z a
ignature of Krrffittee Dye r `
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