HomeMy Public PortalAbout5822 AGNES AVE_Building_3/23/1982_bath tub, lavatory WORKERS COMPENSATION DECLARATION 76A887° APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self c5 s» (z eo)
insure or a certificate of Workers Compensation Insurance or
a cert-ified copy thereof(Sec 3800 Lab C)
COUNTY OF LOS ANGELES BUIL ND SAFET
Policy No Compan
Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM FEE ADDRESS
department WATER CLOSET LOCALITY
Date Applicant NEAREST
BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE SHOWER OWNER
LAVATORY MAIL
(This section need not be completed if the work involved ADDRESS >,
by the permit is for one hundred dollars ($100) or less) SINK CITY TEL
I certify that in the performance of the work for which this DISHWASHERV
permit is i,sued I shall not employ any person in any manner CONTRACTOR Cr
so as to become subject to the Workers Compensation Laws CLOTHES WASHER ADDRESS Q�` 0
Date Applicant SWIMMING POOL RECEPTOR *VALIDA9T1
NOTICE TO APPLICANT If after makingthis Certificate of CITY
Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE
Compensation provisions of the Labor Code you must forth LICENSE NO ��� !
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked GAS SYSTEM OUTLETS DIST NO
LICENSED CONTRACTORS DECLARATION OUTLETS OVERI hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM9 (commencing with Section 7000) of Division 3 of the Busi FINAL
ness and Professions Code and my license is in full force and DATE
effect
-/,� j
License Number. Class FINAL
t5 Contractor Date
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051 Bus
iness and Professions Code) TOTAL FEE t�
Lic or Reg No Date Plan check applicant
-233&OA
HOME OWNER BUILDER DECLARATION Name # 0 o o o o 5
I hereby affirm that I am exempt from the Contractors Address 2 0 0 1650
License Law for the following reason (Section 7031 5 Busi City Tel No o'o o 1 16 5 0
ness and Professions Code)
0323-82
I as owner of the property am exclusively contracts^g
with licensed contractors to construct the project
(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
r
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 and State laws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above me boned property for inspection purposes
I .(t Gu qW. �3 -J o-C- -
Stgriature of Permittee IDate