HomeMy Public PortalAbout4919AGNES AVE_Plumbing (5) WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
6A66
1 h'erebq, affirm that I have a certificate of consent to self in- 76 DPW 4/87
6A667A"
-<u—re, or'a certificate of Workers'Compensation Insurance,ora CE 817(REV. 8/86) '
certified copy thereof (Sec.13800, Lab. C.)
COUNTY OF LOS,ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
0 Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
❑ Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET(TOILET), �� J
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER %®
(This section need not be completed if the.work involved by MAIL
the permit is for one hundred dollars ($100)'or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per SINK
mit is issued, I shall riot employ any person in any manner so -CITY T �
J
as to become subject to the Workers' o nsation S. DISHWASHER
CONTRACTO d Gly.C / rs
Date_ plic CLOTHES WASHER ,
ADDRESS
�
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
SWIMMING POOL RECEPTOR
emption, you should become subject to,the Workers'Compen- CITY �_/
m ��J 9
sation provisions of the Labor Code, you must forthwith cop- LAWN SPRINKLER SYSTEM �J
ly withsuch provisions or this permit shall be deemed revok- STATE LIC. �+
ed. -WATER HEATER LICENSE NO�, CLASS G
LICENSED CONTRACTORS DECLARATION GAS SYSTEM / DISTRICT NO. PROCESSED BY
OUTLETS
I-hereby affirm that I am licensed under provisions of.Chapter �j (/
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER epi e a
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect• DATE
License Numb@ c. Class O
� � ��� f �d FINAL V
Contre _�2 �/� Dated J/ (J % BY 0
O
I am exempt under Sec. U
UJ
B.&P.C. for this reason 0.
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ ;' -i
Signature r•'• a
TOTAL FEE. t�l•�•f o s
SINGLE FAMILY •-- a� ;!;
HOMEOWNER_BUILDER DECLARATION Plan check applicant 3.07 = n
I hereby affirm that I am exempt from the Contractor's License Name ITEMS
Law for the following reason (Section 7031:5, Business.and _ i. ,,
Professions Code): Address TOTAL L 30
I, as owner of the property, will do the work and the City Tel. No. CHECK
" n-+ !
r structure is not intended or offered for sale(Section 7044, a�!
Business and Professions Code). ,
CHANGE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency forDoor,1" 1' (I 1 S/1P,'
the performance of the work'for which this permit is issued -._ a
(Sec. 3097, Civ. C.). 5079 1 AM11 1.19
Lender's Name N
Lender's Address
I certify that I have read this application and state that the 4• '
above information is correct. I agree to comply with all County ,
ordinances and State laws regulating Plumbing, and hereby
resentpof s County to enter upon the
t' e roropertert inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
a