HomeMy Public PortalAbout5749AGNES AVE_Plumbing ,WORKER'S I COMPENSATION DECLARATION 20-0026 DPW
PW 9/89 APPLICATION FOR PLUMB.INGF'"PERMIT, (1
I hereby affirm that have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.) ;!`
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS r DEPT:OF PUBLIe•WORKS DIV.
Policy No. Company ^
Certified copy is hereby furnished. r
ElFOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING '
Certified copy is filed with the county building inspection ACDRESS y
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY'
Date Applicant WATER CLOSET NEAREST "
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB ROSS ST.
COMPENSATION INSURANCE 'ASSESSOR _
(This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE IPARCEL
permit is for one hundred dollars($100)or less.) OWNER
I certify that in the performance of the work for which this permit LAVATORY
is issued, I shall not employ any person in any manner so as to SINK MAIL
become subject to the Workers' Compensation Laws. / ADDRESS: y y
/off DISWASHER cCITY ' ��°� TEL.NO.
Date Z-2 " -�' 9S Applicant v CLOTHES WASHER CONTRACT
NOTICE TO APPLICANT: If, after may this Certificate of
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRES
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
i
LICENSED CONTRACTORS DECLARATION CITY% r TEL.N1O. -5 _ }
_ 6 7
WATER HEATER G.
hereby affirm that I am licensed under provisions of Chapter 9 ' v 4" �S ' t r"�
(commencing with Section 7000) of Division 3 of the Business and T i ''' ', LIG. ' '
STATE- O
Professions Code,and my license is in full force and effect. ✓ GAS SYSTEM f OUTLETS ¢ �� LICENSE._.
OUTLETS OVERI
TRIC T NO. P OCESSED BY
5 PER SYSTEMO
License Number G� ?fit' Lia Class
FINAL '''
/�a -�_� f DATE VAI ATION a
Contractor Date 3 ,`
FINAL # - Z
I am exempt under Sec.
gy
;
B.&P.C.for this reason V J
Date: Plan check fee '?
:.
PLUMBING PERMIT ISSUING FEE$
Signature C i
❑ TOTAL FEE b2l
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION
Name ;:*�". .Af•f••.
I hereby affirm that I am exempt from the Contractor's License Law
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for the following reason (Section 7031.5, Business and Professions Address
Code):
El1,
Tel. No.
I,as owner of the property,will do the work and the 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 Lpq i
performance of the work for which this permit is issued (Sec. 3097, 6831 , riltl3=itJ
Civ.C.) `
Lender's Name G
Lender's Address
I certify that I have read this application and state that the above , ' 2 fj 9
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
gropefor ipeeti n pure/ose. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sl�gyt fu re of Permittee Date