HomeMy Public PortalAbout5118AGNES AVE_Plumbing (4) WORKERS COMPENSATION DECLARATION 78A867A APPLICATION FOR PLUMBING P E R M I T
I hereby affirm that I have a certificate of consent to self CE 817 (z eo)
insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 La C) ` a
COUNTY OF LOS ANGELES BUIL A D SAFE _
Policy No n
Compa
Certified copy is hereby furnishe FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING /
ADDRESS
Certified copy is filed with the county buil ng inspection NUMBER FIXTURE OR ITEM 0 FEE
d LOCALITY
WATER CLOSET
Date t tApplicant NEAREST
BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS r
COMPENSATION INSURANCE SHOWER OWNER
MAIL �}
(This section need not be completed if the work involved LAVATORY n ADDRESS ��� a
by the permit is"for one hundred dollars ($100) or less) SINK TEL O U
CITY NO �Ti !�
I certify that in the performance of the work for which this DISHWASHER CONTRAC OR
permit is issued I shall not employ any person in any mannerX _��] 0
so as to become subject to the Workers Compensation Laws CLOTHES WASHER ° ADDRESS U
Date : Applicant UJI
SWIMMING POOL RECEPTORCITY TEL N /J y Cj
NOTICE TO APPLICANT If after making this Certificate of
Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE Q LIC
Compensation provisions of the Labor Code you must forth LICENSE NO CL70 ASS
deemed
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO PROCESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER r-,0
F
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi FINAL VALIDATION
ness and Professions Code,and my license is in full force and DATE �j �"
effect
( FINAL
License Nu Lic Clas''s BY '
Contractor Date / /' dr.01— I
I,am exemp rom the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051 Bus
iness and Professions Code) TOTAL FEE 5 8 7 3 A
Lic or Reg No Date Plan check applicant o e o o of
HOME OWNER BUILDER DECLARATION T blame 2 °I° 1 250
E 1
I hereby affirm that I am exempt from the Contractor s Address °4° e 1 2 5 0
License Law for the following reascn (Section 7031 5 Busi City Tel No
ness and Professions Code) ' 048 26-82
ElI as owner of the property am exclusively contracting
with licensed contractors to construct the project
(Section 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY ; +
I hereby affirm that there is a construction#lending agency �) ,
for the performance of the work for which this permit is a
issued(Sec 3097 Civ C) e
Lender s Name v
Lender s Address
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 and State laws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above mention$d property o inspection purposes
SignatiVe of Permittee Date
y