HomeMy Public PortalAbout5219AGNES AVE_Plumbing WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self i76A667A
insure or a certificate of Workers Compensation Insurance CE 817(REV 10/81)
or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished
EJ Certified
APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING o�
Certified copy is filed with the county building inspec ADDRESS JOr
tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE OWNER z
(This section need not be completed if the work involved by 11
SHOWER
the permit is for one hundred dollars $100 or less MAIL
p ( ) ) LAVATORY ADDRESS 2
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY TEL NO�� _'9�J
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so as to become subject to the Workers Compensation Laws DISHWASHER /
`� CONTRACTOR �, �1 /9,q
Date �--if—T/ Applicant CLOTHES WASHER
NOTICE TO APPLICANT If after making this ert, ,ca of ADDRESS �,C a i
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM CITY Gr TEL NO
with comply with such provisions or this permit shall be STATE LIC / r
deemed revoked WATER HEATER LICENSE NO tf CLASS C
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS _
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL t� VALIDATION d
DATE '�� ( ( V
License Number f ll4 9 Lic Class fe Q
FINAL 0
Contractor Date BY F.,
❑ I am exempt under Sec Q� 11611,111
W
B 8P C for this reason i9 �L� /
H
Date
Plan check fee ► Z
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION Name r 3 7 b A
I hereby affirm that I am exempt from the Contractor s License Address
Law for the following reason (Section 7031 5 Business and ; o o o o o 5
Professions Code) City Tel No 0 0❑ 1650,
�Jr O j as owner of the property will do the work and the
structure is not intended or offered for sale (Section to 0 0 6j
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY 0718-83
j 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 ) "
Lender s Name
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
ordinances and State jaws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above mentioned property for inspection purposes
A b p� SEE REVERSE FOR EXPLANATORY LANGUAGE
40 / —/a `� J
Signature o Per itt a Date