HomeMy Public PortalAbout5117AGNES AVE_Plumbing (4) Y _WpRKER S COMPENSATION DECLARATION �_ 76A6 76 ADPW 9/69 APPLICATION FOR PLUMBING PERMIT
' I hereby affirm that I have a certificate of consent to self insure
or a certificate of Worker s Compensation Insurance or a certified
copy thereof(Sec 3800 Lab C) � �
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
Policy No Company r
❑ Certified copy is hereby furnished BUILDING
F-1ADDRESSAPPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county budding inspection
department NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST ���
COMPENSATION INSURANCE ASSESSORMAP BOOK �pL1 p-/ PAGE�k PARCELQ�
(This section need not be completed if the work involved by the SHOWER I
permit is for one hundred dollars($100)or less) LAVATORY OWNER
I certify that in the performance of the work for which this permit
At
is issued I shall not employ any person in any manner so as to SINK ADDRESS��1 ,(�p
become subject to the Workers Compensation L w -- F s
�—�Z i DISWASHER CITY G� �r TEL NO
Dab V Apphca t CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT If a!Kr-maung this Certific a of
Exemption you should become subject to the Workers Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code you must forthwith comply with such
provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL NO
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER a
(commencing with Section 7000 of Division 3 of the Business and STATE LIC Q
( 9 ) LICENSE NO CLASS
Professions Code and my license is in full force and effect GAS SYSTEM OUTLETS (�
OUTLETS OVER DISTRICT NO PROCESSED BY O
5 PER SYSTEM
License Number Lic Class ~'
FINAL
DATE VALIDATION W
CL
Contractor Date at - a co
❑ FINAL �� - `Z
I am exempt under Sec BY _Lj j_
B&P C for this reason 5
Date
Plan check fee , i T EM=
�
Signature PLUMBING PERMIT ISSUING FEE$ �� I fl- -172 753
ElTOTAL FEE S f r�
Plan check applicant
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractors License Law _ _
for the following reason (Section 7031 5 Business and Professions Address 0 lD-�_st_1 v
Code)
� City Tel No r'M a _1
I as owner of the property will do the work and the structure )
is not intended or offered for sale (Section 7044 Business
and Professions Code)
CONSTRUCTION LENDING AGENCY 1
I hereby affirm that there is a consCruction lending agency for the I
performance of the work for which this permit is issued (Sec 3097
Civ C) I J,
Lender s Name
r
Lender s Address
f
1 certify that I have read this application and state that the above
inforriation is correct I agree to comply with all County ordinances
and State laws regulating Plumbing and hereby authorize -
representatives of this County to enter upon the above mentioned
property for ct rr ur e SEE REVERSE FOR EXPLANATORY LANGUAGE
Sigiiature of Permittee Date