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HomeMy Public PortalAbout5226AGNES AVE_Plumbing WORKERS'coMPENSA11oN DECLARATION 20-0026 DPW.4/87 APPLICATION FOR PLUMBINGPERMIT �I her&b affirm that I have a certificate of consent to self in 76A667A sure, or a•certificate of Workers'Compensation Insurance, or a CE 817(REV. 8/86) certified copy thereof (Sec. 3800, Lab. C. `fl COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Pollcy NQ. Company t 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 ��in7//�� LOCALITY Date Applicant Z, WATER CLOSET(TOILET) VV NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 19 O CROSS ST. COMPENSATION INSURANCE SHOWER ®o OWNER 4,4R (This section need not be completed if the work involved by MAIL . / the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- m er- SINK mit is issued, I shall not employ any person in any manner so 00 CITY TEL. NO.,ZV-7—/'Z as to become subject to the Workers'Compensation La s. /r DISHWASHER �0 ( /� CONTRACTOR Date y "Applicant CLOTHES WASHER ®ld ADDRESS NOTICE TO APPLI NT: If, after making this rtificate of Ex- SWIMMING POOL RECEPTOR emotion, you should become subject to the orkers'Compen- CITY TEL NO. sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATERLICENSE NO. CLASS '•LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED.BY s I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ` 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER d Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL feIf.-A-414 VALIDATION DATE ,y 0. O License Number Lic. Class U FINAL Contractor Date BY ♦ O I am exempt under Sec. B.BP.C. for this reason ► Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ 1,060 Signature TOTAL FEE © U SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant 1229-88 1 hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and Professions Code): Address. ' I, as owner of the property, will do,the work and the• City Tel. No. structure is not intended or offered for sale(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 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 laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned propty for inspection purposes. Q SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P mittee D e 0 ' r