HomeMy Public PortalAbout5732AGNES AVE_Plumbing (4) 1 WOR`4*-RS COMPENSATION DECLARATION zsAeszw �C7111J�'1,'1
I hereby affirm that I have a certificate of consent to self CE e» (z so) APPLICATION FOR PLUMBING PERMIT
insure or a certificate of Workers Compensation Insurance or <
a certified copy thereof(Sec 3800 Lab C) f
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company I r
Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
❑ ADDRESS v—
department WATER CLOSET
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE
LOCALITY ToJ /
IF-
Date— Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved LAVATORY MAIL +�
ADDRESS 6. D }
by the permit is for one hundred dollars ($100) or less) SINK CITY , TEL N O S .e.- O
I certify that in the performance of the work for which this OakDISHWASHER U
permit is issued I shall not employ any person in any manner CONTRACTOR Q
so as to become subject to therfers Competsation aws CLOTHES WASHER
/ ADDRESS O
Date —�B-f� Applicant SWIMMING POOL RECEPTOR V
NOTICE TO APPLICANT If after making this Cea ificate of CITY TEL NO LU
Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE LIC iL
Compensation provisions of the Labor Code you must forth WATER HEATER LICENSE NO z
with comply with such provisions or this permit shall be
PROC SSED BY
deemed revoked GAS SYSTEM 2_ OUTLETS DISTRICT NO..,-.
LICENSED CONTRACTORS DECLARATION OUTLETS OVER � }
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Bust FINAL VALIDATION
ness and Professions Code and my license is in full force and DATE
effect }
FINAL
License Number Lic Class BY
Contractor Date
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional eng neer
PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051 Bus �
ine.s and Professions Code)
TOTAL FEE t
Lic or Reg No Date Plan check applicant
HOME OWNER BUILDER DECLARATION Lau-ss QI hereliy�affirm that I am exempt fr the Contractor sLicense Law for the following re (Section 7031 5 Bust ^ Tel No
nes and Pro Bions Code)
I as owner property am exclusively contracting
���TTT111 with licen ntractors to construct the project
(Sect 044 Bus ss and Professions Code) -921 53A
CONSTRUCTION ENDING AGENCY
I hereby affirm that there is a construction lending agency # 0 0 0 0 o v
for the performance of the work for which this permit is _ 2 o e 2
issued(Sec 3097 Civ C)
500
Lender s Name
Lender s Address
0916-80
1 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 P mbing and hereby
authorize representatives of this ou y to enter upon the
above-mentioned opert or pec n purposes
S nature of Per tt a r Date
.� l l