HomeMy Public PortalAbout5742AGNES AVE_Plumbing b,, 9 WORKERS' COMPENSATION CCLARATION APPLICATION FOR PLUMBING PERMIT
26A667 DPW 4/87
J h,�reby,-affirm that I have a certificate of consent to self in- 76A667A
suave,,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
,certified copy thereof (Sec. 3800, Lab. C.)'
COUNTY OF LOS ANGELES DEPT. OF PUBLIC.WORKS
Policy No. Company
F Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �7f4A AMS Ae
Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY lem
WATER CLOSET(TOILET) �(� J04 C.,
Date Applicant 0 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST. ed OA&MIf1-01 e—
COMPENSATION INSURANCE SHOWERQ� OWNER , �f
(This section need not be completed if the work involved by MAIL �1
the permit is for one hundred dollars ($100)or less.) LAVATORY DQ ADDRESS �/ .�es A,
I certify that in the performance of the work for which this per- SINK.
mit is issued, I shall not employ any person in any manner so CITY TEL. NO.gpr^ 79?
as to become subject to the Workers'Compensation Laws. DISHWASHER A"Ol7 J
CONTRACTOR
Date 0 �� ApplicantCLOTHES WASHER 067
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex= SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- O CITY TEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER Q LICENSE NO. SS
LICENSED CONTRACTORS DECLARATION DISTRICT N ROCE DW
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS Qo
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER i
and Professions5 PER SYSTEM Code, and my license is in full force and ef- FI VALIDATI
fect. D ,T V @s
License Number Lic. Class S
F t$
Contractor Date / / O
• I am exempt under Sec. 1AJ
B.&P.C. for this reason Plan check fee pop. g
Date: PLUMBING PERMIT ISSUING FEE$ O 8.0 9.8 A
Signature
TOTAL FEE Q
SINGLE FAMILY # 0 0 0 0,0 5
HOME OWNER-BUILDER DECLARATION Plan check applicant (;0`0 5 a 5 0
1 hereby affirm that I am exempt from the Contractor's License Name =
Law for the following reason (Section 7031.5, Business and ° ° ° 5&5.0 5
Professions Code): Address
3 1 817
I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY ;
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 ►
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspection.purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
�Signatud, of Permittee bate