HomeMy Public PortalAbout4846 AGNES AVE_Plumbing_9/18/1989_gas system (3) WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No.` r Company r 'Jai
❑>Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �
17 Certified copy is filed with the county building inspec- ADDRESS L L"
tion department. NUMBER FIXTURE OR ITEM C FEE
LOCALITY
Date
Date "l Applicant �`/ rl ^W WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. Z
COMPENSATION INSURANCE OWNER
SHOWER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS (14
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHERt --
CONTRACTOR t
Date Applicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO. r"
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT O. PROCESSED BYr
GAS SYSTEM UTLETS
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I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL M VALIDATION U
License Number Lic. Class DATE LLIJ
FINAL Ly
Contractor Date BY
❑ I am exempt under Sec. ¢,
B.BP.C. for this reason
Er
Plan check fee 0
Date: PLUMBING PERMIT ISSUING FEE$ j " j �
Signature W
TOTAL FEE
Plan check applicant J t
SINGLE FAMILY F'
HOME OWNER-BUILDER DECLARATION Name
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 1 Tel. No.
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (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
.V92,_.Cv. 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 laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
bb v. ntioned property for inspection purposes.
f ,n SEE REVERSE FOR EXPLANATORY LANGUAGE
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ign ur f mitt Date