HomeMy Public PortalAbout5733AGNES AVE_Plumbing (3) WORKERS COMPENSATION DECLARATCN 76AG67A r6}APPLICATION FOR PLUMBING PERMIT {�
I hereby affirm that I have a certificate of consent to self ce 817'(2 so) �J
insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec LL��-jog Lab�) � � COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy o o0C_{/Coempar<ya '
Ell Certified copy is hereby furnishe FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
Certified co � / � NUMBER FIXTURE OR ITEM • FEE ADDRESS
copy is filed with the county�u1ldmg inspection
p
�1e artment WATER CLOSET LOCALITY 6
Date Applicant NEAREST
BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS k
COMPENSATION INSURANCE SHOWER OWNER PW
/)
MAI L
(This section need not be completed if the work involved LAVATORY ADDRESS
by the permit is for one hundred dollars ($100) or less) /]
K CITY EL NO /-7 0
I certify that in the performance of the work for which this DISHWASHER U
permit is i,sued I shall not employ any person in any manner CONTRACTO a
so as to become subject to the Workers Compensation Laws CLOTHES WASHER0
ADDRESS
Date Applicant SWIMMING POOL RECEPTOR U
NOTICE TO APPLICANT If after making this Certificate of CITY �T1��V y ---- TIIL NO W
Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM STATEj LIC N
Compensation provisions of the Labor Code you must forth LICENSE NO -k+— CLASS z
with comply with such provisions or this permit shall be WATER HEATER —
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO RO SSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi FINADATE �' .- VALIDATION
ness and Professions Code and my license is in full force and
effect r
FINAL
License Number Lic Class P' gY
Contract to ITi—(Q b I
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051 Bus
iness and Professions Code) TOTAL FEE
Lic or Reg No Date Plan check applicant
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractors Address z 2 2 6 Q A
License Law for the following reason (Section 7031 5 Busi City Tel No
ness and Professions Code) # 0 0 0 0 0 5
DI as owner of the property am exclusively contracting 2 °F° 1 5 0
with licensed contractors to construct the project
(Section 7044 Business and Professions Code) ° ° 0 1 6 5 0 c=i
CONSTRUCTION LENDING AGENCY 1 2 1 -81
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec 3097 Civ C)
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances.4h State laws regulating Plumbing and hereby
authori6pllvpresentatives of this County to enter upon the
above a one rt for inspection purposes'Ina A/:
•
Z-1,o
Sigfiature of rmittee Date
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