HomeMy Public PortalAbout4846 AGNES AVE_Plumbing_9/18/1989_GAS SYSTEM WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
° 1 ho eby off rm that I have a certificate of consent to self 20 0026 DPW 6/87
Oir0 or a cert f cote of Workers Compensation Insurance 76AS67A
cert fled copy thereof(Sec 3800 Lob C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Pal cy rlo67ls7 bl' ompany STATE T-1
li? Cert fled copy s hereby furnished BUILDING
i FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy s filed w th the county building inspec
tion department tNUMBER FIXTURE OR ITEM Q FEE
��9 LOCALITY
Date L�� /�( Appli4ant WATER CLOSET NEAREST � � /
CERTIFICATE OF EXEMPTION FROM WORKERS
BATH TUB CROSS ST W
COMPENSATION INSURANCE SHOWER OWNER — L
(This section need not be completed if the work involved by MAIL /1
the permit is for one hundred dollars($100)or less ) LAVATORY Z of e
ADDRESS
1 cert fy that in the performance of the work for which this
permit s issued I shall not employ any person in any manner SINK CITY T TEL NO
so as to become subject to the Workers Compensation Laws DISHWASHEREt
CONTRACTOR ■ II
Date Appl cant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after mak ng this Certificate of SWIMMING POOL RECEPTOR
Exemption you should become subject to the Workers CITYr TEL NO
Compensat on pro is ons of the Labor Code you must forth LAWN SPRINKLER SYSTEM ��� J
with comply with such provisions or this permit shall be STATE LIC �yn�
deemed revoked WATER HEATER LICENSE NO CLASS 2V
LICENSED CONTRACTORS DECLARATION DISTRICI NOPROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS00
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER � }.
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL VALIDATION p;
-7M,-
DATE t( C8
License Number L c Class
FIN noContractor Date 0)
❑ I am exempt under Sec
B&P C for this reason Plan check fee N
Date PLUMBING PERMIT ISSUING FEE$ �� Z
Signature
TOTAL FEE 1(060
SINGLE FAMILY
Plan check applicant Loa N HOME OWNER BUILDER DECLARATION Name ACCT s
,v
I hereby affirm that I am exempt from the Contractor s License Address 3M7 16 '.50
Law for the follow ng reason (Section 7031 5 Business and +r �a—
Professions Code) City Tel No 1 ITEMS
ElI as owner of the property will do the work and the TOTAL 16.50
structure is not intended or offered for sale (Section ® �� ib 51117044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY
(NAPE 00
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec 3097 C v C )
M-Owl 9/13/89
Lender s Name 57951 1 AM 8 12
Lender s Address
I cert fy that I have read this applicat on 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
bo�mentioned property for inspect for inspect on purposes �p SEE REVERSE FOR EXPLANATORY LANGUAGE
Ag r of ermittee Date