HomeMy Public PortalAbout4846 AGNES AVE_Plumbing_7/6/1989_water fixtures .L. f i
,y�to+ S COMPENSATION DECLARATION � 76A667A � ; APPLICATION FOR PLUMBING PERMIT
F hereby off
ff m m that I have a cert ficate of consent to self in
20 0026 DPW 4/87
sure or a certif cote of Workers Compensation Insurance or a CE 817(REV 8/86) f s
aertif ed copy thereof (Sec 3800 Lab C )
Poli y No112-773&-company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS k q
• ` ` > ✓ �4L 4 i�
Ce�f ed copy is hereby furn shed"
o t FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING e
Certified copy s filed with the county building inspect on ADDRESS 494K Aan
department t w r ���i/// NUMBER FIXTURE OR ITEM @ FEE LOCALITY t
FF /` A
Date Appl cant ��23A l� WATER CLOSET(TOILET) O
r• � NEAREST
e $ CERTIF ATE OF EXEMPTION FROM WORKERS -" ' BATH TUB ' CROSS ST " e 3
a r COMPENSATION INSURANCE i SHOWER OWNER r }
(This section need not be completed if the work involved by ' S MAIL s
the permit is for'one hundred dollars($100),or less ) LAVATORY fl= + t 6 0 d ADD ESS
` { t r
I certify that in the performance of the work for which th s per r
mit is'ssued I shall not employ any person in any manner so +w w SINK y p CITY rTEL NO T^ $
osdto become subject to the Workers Compensation Laws DISHWASHER 'e 9
r
V. 'A .1 t #r � 9 It, r " ^ +� 4i � t ` CONTRACTOR �
Date^ r x Applicant w h s w i CLOTHES WASHER 01 ADDRESS d 4
NOTICE TO APPLICANT If after makingkth s Cert f cafe of Ex o SWIMMING POOL RECEPTOR F x
emption you should become subject to the Workers Compen CITY r TEL NO x
sation provisions of the Labo,,Code you must forthwith comp LAWN SPRINKLER SYSTEM 4 �-
ly with such pro sions or this permit shall be deemed re okSTATE a p LIC
ed,,, k W y "f 4 . r m WATER HEATER r ` ti LICENSE NO 7 2 CLASS t e
4 jee a LICENSED„CONTRACTORS DECLARATION ,, ` Y d ` A DISTRICT N PR ESSE BY
I hereby off m that I am licensed under prov s ons of Chapter t GAS SYSTEM '+ OUTLETS `
9(commenycingtw th Sect on 7000)of Division 3 of the Bus nes s >4 r OUTLETS OVER -• J b
k and Professions Code and my I cense is n full force and of 5 PER SYSTEM- � + � a' +
fect s ti x r r t e FINALDATE �� 1 r VALIDATION
Li cense Number } n t tic Class d ¢ & r s F R a ; V
Vol
ContractorinP� l Ohl Date v Y 6 O
Iti m exempt under Sec } w „ a y y a t -� r W
s
.. B&P C for this reason �° �+ e Plan check fee (a k ., r � � r Z
ti X41�� "'"Date PLUMBING PERMIT ISSUING FEE$
�� ��
A'%Signature
$� av s
M- j z TOTAL FEE T
r SINGLE FAMILY + ,1
x Plan check applicant
HOME OWNER BUILDER DECLARATION PP a k a a � a y
1 hereby affirm that I am exempt from the Contractor s License Nome - 'r k J a '"
Law for the follow ng eason (Sect on 7031 5 Business and s v
Professions Code) Address, , 7 r
s 28
F-1# I as owner of the property w II do the work and the C ty • a" `Tel No r� d" % 1 ITEM f i
structure is not intended or offered for sale(Sect on 7044
Business and Profess ons Code) n s 3 rr f ti ti TnTAL_ 28.50
r-a CONSTRUCTION LENDING AGENCY $ # r 'r a s kr a CHECK � k28 %
I hereby off rm that there s a const uct on lend ng agency for r .� 4 w
the performance of the work4for which tthis permit s issued a ' f s "k�7 { ' ' T t 7 CHANE 4 00
f (Sec 3097 Civ C ) A tit y k i y
Lender s Name "� a y 0000-0001 7/' 6/89
' r a E S f 4349 1 AM11 4S
r ''Lenders Address v f r , T f
I certify that I have read th s application and state that the ' } + f { s � - t Aa$1 R '
abo a information is correct I agree to comply with all County °t s ® F V d
ordinances and State jaws regulat ng,Plumbing and hereby
< author ze representatives of this County to enter upon the Y s
above ment oned property for nspection purposes
SEE REVERSE FOR EXPLANATORY*LANGUAGE r
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