HomeMy Public PortalAbout5226AGNES AVE_Plumbing (6) WORKERS COMPENSATION DECLARATION 76AG67A
I hereby affirm that I have a certificate of consent to self CE e17 (i 60) APPLICATION FOR PLUMBING PERMIT {j
insure or a certificate of Workers Compensation Insurance or I J
a certified copy thereof(Sec 3800 Lab C) L
I COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company R
Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING C
ADDRESS
✓ Z(0 6�'�j/!/ { 5�—
O Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM i FEE LOCALITY �� /E ��T 7�7
department
Date Applicant WATER CLOSET NEAREST //��
BATH TUB CROSS ST QWLA?✓y!
'CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE s SHOWER OWNER
(This section need not be completed if the work involved LAVATORY ADDRESS J y S
by the permit is for one hundred dollars ($100) or less) a
SINK CITY l TEL N0,?e7#17 O
I certify that in the performance of the work for which this DISHWASHER r" U
permit is i.,sued I shall not employ any person in any manner CONTRACTOR ���� cc
so as to become subject to the Workers Compensation Laws C CL
OTHES WASHER Oy ADDRESS
Date Applicant SWIMMING POOL RECEPTOR r U
NOTICE TO APPLICANT If after making this Certificate of CITY TEL NO W
Exemption +you should become subject to the Workers LAWN SPRINKLER SYSTEM CL
STATE LIC to
(Compensation provisions of the Labor Code you must forth WATER HEATER LICENSE NO CLASS
with comply with such provisions or this permit shall be
deemed revoked ` GAS SYSTEM OUTLETS DISTRICT NO P CESSED BY
1- LICENSED CONTRACTORS DECLARATION + OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi FINAL VALIDATI IV
ness and Professions Code and my license is in full force and DATE y
effect d
FINAL
License Number Lic Class BY
i
Contractor Date
DI am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a +registeiedl,�profession a] engineer
acting in my professional c`apacity��(Section 7051 Bus PLUMBING PERMIT ISSUING FEE$
mess and Professions Code) ` TOTAL FEE
Lic or Reg No Date Plan check applicant
J
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractors Address
License Law for the following reason (Section 7031 5 Busi City Tel No
ness and Professions Code) ;2 2 0,7
6 A
EJI as owner of the property am exclusively contracting
with licensed contractors to construct the project # o o o o o 5
(Section 7044 Business and Professions Code) " ,
CONSTRUCTION LENDING AGENCY
2,o to 2 a 0 0
I hereby`affirm that there is a construction lending agency 0 0 0 2 0 0
for the performance of the work for which this permit is
r
issued (Sec 3097 Civ C)
Lender s Name r 1 1'24-8,1
Lender s Address
I certify that Ive read this application and state that the °
above mformati correct I agree to comply with all County
ordinanccs d to la egulatii Plumbing and hereby SEE REVERSE FOR EXPLANATORY LANGUAGE
authorize e e e t tives thi ounty to en r upon the
above nti d p spection purpo s
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SignatuiVelf i at �i