HomeMy Public PortalAbout5733AGNES AVE_Plumbing WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 ti
insure or a certificate of Workers Co ensotion Insurance 76A667A
ora certifi cop thereof (Sec 38 6 C COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No nmpa
❑ Certified copy is hereby furnis cI
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building mspec ADDRESS
tion department NUMBER FIXTURE OR ITEM @ FEE
9 {� LOCALIT
Dat� Applican WATER CLOSET O t NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERSBATH TUB CROSS S
COMPENSATION INSURANCE / SHOWER OWNER
(This section need not be completed if the work Involved by
the permit Is for one hundred dollars ($100)or less ) LAVATORY MAIL /
�4 �" ADDRES `0 LC/y/
Y certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner �— SINK CITY TEL
so as to become subject to the Workers Compensation Laws / DISHWASHER.
CONTRAC OR b
Date Applicant / CLOTHES WASHER ADDRES
NOTICE TO APPLICANT If after making this Certificate of �O d
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth CIT TEL —arS
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE �j LIC
deemed revoked WATER HEATER I LICENSE NO O CLASS
LICENSED CONTRACTORS DECLARATION DSTRI T PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM t OUTLETS
Icommencing with Section 7000) of Division 3 of the Business OUTLETS OVER d
and Professions Code and my license is m full for an effect 5 PER SYSTEM
FINAL V DA ION
�/ DATE10 0
r License um r �a Lic Class V
04� p 9 �� � .8_j -- FINAL
Contrac r DateAle!
' O BY
❑ ~
I am exempt under Sec ()
W
B 8P C for this reason Plan check fee w r S U)
Date PLUMBING PERMIT ISSUING FEE$ Q Z
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION Name ° =�t')7 iO•�
I hereby affirm that I am exempt from the Contractor s License Address — 1 ITEt11
Law for the following reason (Section 7031 5 Business and T�1 TAL 133 - 00
Professions Code) City Tel No
❑ I as owner of the property will do the work and the CHECK 16-8.00
structure is not intended or offered for sale (Section , HAhI�E 1�l i
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for ,y
the performance of the work for which this permit is issued 00OCi-0001 12/ 1/8Q
(Sec 3097 Civ C )
7191 1 i-1f'I 8.1i
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 jaws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
a ove men lone property for inspection purposes g
SEE REVERSE FOR EXPLANATORY LANGUAGE
$gnature of Permittee l�s�— !!/�i Date