HomeMy Public PortalAbout5817AGNES AVE_Plumbing (3) WORKERS COMPENSATION DECLARATION20 APPLICATION FOR PLUMBING PERMIT
I herebyaffirm that I have a certificate of consent to self DPW a/90
in 76A6676A667A
sure or a certificate of Workers Compensation Insurance or a n
certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS IIuII
Policy No -�CompanySCLVE
❑ Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS
department NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET(TOILET)
Date Applicant / NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNE 1 � LL
(This section need not be completed if the work Involved by MAIL
the permit is for one hundred dollars (;100)or less) LAVATORY ADDRESS
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 CITYR'� TEL NO �
as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTORa
Date Applicant CLOTHES WASHER ADDRESS S
NOTICE TO APPLICANT If after making this Certificate of Ex SWIMMING POOL RECEPTOR �-
emption you should become subject to the Workers Compen CITY,— TEL NO
Z&7 247
satton provisions of the Labor Code you must forthwith comp LAWN SPRINKLER SYSTEMS J. C Of
ly with such provisions or this permit shall be deemed revok STATE �tL, LIC
ed WATER HEATER LICENSE NO C'�d CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and of 5 PER SYSTEM FINAL VALIDATION
fect HOSE BIB DATE
License Number !� Lic Class �` a
FINAL O
Contractor Date �' Y r V
Q
I am exempt under Sec pIV ACCTeg
B 8P C for this reason 3303 7- 6 ,
Date 1 ITEMS Plan check fee ► W Z
PLUMBING PERMIT ISSUING FEE$ �
Signature TOTAL _75. 60
TOTAL FEE
SINGLE FAMILY CHECK 75,60
HOME OWNER BUILDER DECLARATION Plan check applicant �L�
I hereby affirm that I am exempt from the Contractor s License Name CHANGE .00
Law for the following reason (Section 7031 5 Business and
Professions Code) Address
El I as owner of the property will do the work and the City Tel No DODO-0001 7, 1/96
structure is not intended or offered for sale(Section 7044 4658 1 AM 9:39
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 jaws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above oned pro er y for inspecti�poses
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign ture of Permi tee Date