HomeMy Public PortalAbout5729AGNES AVE_Plumbing WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure or a icertificate of Workers Compensation Insurance CE 817(REV 10/81) r E
or a certified copy thereof (Sec 3800 Lab C ) t COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NoWCW 30973-�-73�oany West American Ins
Certified copy is hereby furnished C `
® ° FOR APPLICANT TO FILL IN(PRINT OR TYPE) BULDIN
ADDRESS 5 729 Anes
Certified copy is filed with the county building inspec
tion department NUMBER FIXTURE OR ITEM ® FEE LOCALITY Tem le Cityi d
x
Date Applicant WATER CLOSET NEAREST ,,lJ
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION,INSU RANCE„- SHOWER OWNER Jabergu
(This section need not be completed if the work involved by
a the permit is for one hundred dollars ($100)or less ) MAIL
LAVATORY ADDRESS 5729 Agnes
I certify that in the performance of the work for which this
permit is issued I shall not employ any perso%in any manner SINK ° CITY Temple City TEL NO 89-0
546
so as to become subject to the Workers Compensation Laws DISHWASHER
t a CONTRACTOR Economy Plumbing M
Date Applicant CLOTHES WASHER ` ADDRESS 1580 East Walnut Street
NOTICE TO APPLICANT If after making this Certificate of
Exemption you should become subject to the Workers, a SWIMMING POOL RECEPTOR r 5
Compensation provisions of the Labor Code you must forth CITY Pasadena 91106 TEL N0449-1910
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE 247190 LIC C36 SC20
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commenting with Section 7000) of Division 3 of the Business OUTLETS OVER
and Profes c and my license is,n full force and effect j 5 PER SYS/T�EM FINAL f' VALIDATION °
License Number /5 /��� Lic Classes— "�� l��� DATE I �""< ' O
V
FINAL °
Contractor Date BY 0
❑ I am exempt under Sec / LU
B&P C for this reason n
� N
I Plan check fee � � Z
Date ,
PLUMBING PERMIT ISSUING FEE$ O
Signature
' TOTAL FEE v
y TZ5 f 92A
Plan check applicant
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Name ' m o o o o 5
1 hereby affirm that I am exempt from the Contractor s License Address ' , c p
Law for the following reason, (Section 7031 5 Business End 2 0 04650
❑Professions Code) City : Tel No o?o 0465025 1
I as owner of the property vvQ1 do the work and the 1
t ti structure is not intended or offered for sale (Section ' O 05-8,3
7044 Business and PrOfessibns Code)
CONSTRUCTION LENDING AGENCY r a
I hereby affirm that there is a construction lending agency for z
the performance of the work for which this permit is issued ti
(Sec 3097 Civ C ) d y
h
r i i
, r 1
Lender s Name
r
Lender s Address s >
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 p s
authorize representatives of this County to enter upon the
ab m tioned property for inspection pqjrposes
� SEE REVERSE FOR EXPLANATORY LANGUAGE a
s
Signature of Permittee Ir
to