HomeMy Public PortalAbout5729AGNES AVE_Plumbing (3) WORKERS COMPENSATION DECLARATION 76A887A
I hereby affirm that I haFe a certificate of consent to self ce e17 (2 e0) APPLICATION FOR PLUMBING PERMIT {�
insure or a certificate of Workers Compensation Insurance or
a certifie co thereof Se 3800 Lab C)
VA��—�719 — — COUNTY OF LOS ANGELES ' BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
Certified copy is filed with the untyuildmg nspe n
NUMBER FIXTURE OR ITEM • FEE ADDRESS Cr'
pie rt ent WATER CLOSET LOCALITY
Date Applicant NEAREST
BATH TUB CROSS ST
CERT FICATE OF EXEMPTION FRO WORKERS
COMPENSATION INSURANCE SHOWER OWNER �t�
LAVATORYMAIL s
(This section need not be completed if the work involved ADDRESS >-
by the permit is for one hundred dollars ($100) or less) SINKa
CITY TEL NO 0
I certify that in the performance of the work for which this DISHWASHERU
permit is i sued I shall not employ any person in any manner CONTRACTOR I 66z,,�� t m&—^' cc
so as to become subject to the Workers Compensation Laws CLOTHES WASHER O
ADDRES
Date Applicant SWIMMING POOL RECEPTOR U
NOTICE TO APPLICANT If after making this Certificate of CITY TEL NO d
Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE LIC N
.Compensation provisions of the Labor Code you must forth WATER HEATER LICENSE NO CLASS If-63 Z
with comply with such provisions or this permit shall be
deemed revoked i GAS SYSTEM -9—OUTLETS DISTRICT NO P CESSED"B
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi FINAL !�/ VALIDATION
ness and Professions Code and my license is in full force and DATE o
effect
FINAL
License Number Lic Class C-56 FINAL
r
Contractor Date
QI am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051 Bus
iness and Professions Code) TOTAL FEE SV
Lic or Reg No Date Plan check applicant
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 ;22231 A
ness and Professions Code)
# 0 000 05
I as owner of the property am exclusively contracting
with licensed contractors to construct the project _ 2 0 o 1 ,650
(Section 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY 0 — 165020: 4
I hereby affirm that there is a construction lending agency .I 209-81
for the performance of the work for which this permit is
issued(Sec 3097 Civ C)
Lenders 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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing and hereby
authoriz pre entatives f this C ty to enter upon the
above a io r for msp n purposes
l
f. w
i at r tte Date