HomeMy Public PortalAbout5752AGNES AVE_Plumbing (2) WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure or a certificate of Workers Compensation Insurance CE 817(REV 10/81)
or a certified copy thereof (Sec 3800 Lab C ) _ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec ADDRESS 5752 N Agnes
tion department NUMBER FIXTURE OR ITEM @ FEE Temple City
t
LOCALITY P Y
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER R i ch a rd E b e r h a r d t
(This section need not be completed if the work involved by MAIL same
the permit is for one hundred dollars ($100)or less ) LAVATORY ADDRESS
I certify that in the performan"wokhichr which ispermit is issued I shall not emny a SINK CITY Tem le City TEL NO
so as to become subject to the ti n rDISHWASHER CONTRACTORO n t rO 1 Ene rgy
Dat �Applican CLOTHES WASHER ADDRESS 1 3 3 2 N M I 1 1 e r
NO ICE TO APPLICANT If after making this Certificate of
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth CITY TEL N
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM
STATE 463595 LIC
deemed revoked
WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NOP E ED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS /� S/ r
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER f (J o
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINALVALID ION CL
License Number 463595 Lic Class ( 4 4 l S o l a r P 00 l H t DATE 'r� V
Control ENe rgy 5/30/86 A MO S 9 FIN O
Contractor Date B
❑ I am exempt under Sec d
B&P C for this reason h
Date
Plan check fee 1011. z
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION Name 4 Q A
I hereby affirm that I am exempt from the Contractor s License Address
Law for the following reason (Section 7031 5 Business and
Professions Code) City Tel No # o o o o o 5
❑ I as owner of the property will do the work and the o 0 3 0 5 0
structure is not intended or offered for sale (Section '
7044 Business and Professions Code) o oto 3 0 5 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 0 603-86
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 poll,
information is correct I agree to comply with all County
ordinances and State jaws regulating Plumbing and hereby
authIc
representatives of thi ounty to enter upon the
abontione prop ty r i ction purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
0-?O)�b
Sig nat re of Permittee D e T
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