HomeMy Public PortalAbout4846 AGNES AVE_Plumbing_11/6/1989_water heater, gas system WORKERS COMPENSATION DECLARATION 2APPLICATION, FOR PLUMBING PERMIT d
rl hereby affirm that I have a certificate of consent to self in 76 DPW 4/87 A667667A � e
sure or a certificate of Workers Compensation Insurance'or a CE 817(REV 8/86) p +
t certified copy thereof (Sec 3800 Lab C ) x 4 t
" _ � nCOUNTY OF LOS ANGELES DEPT"OF PUBLIC WORKS
Policy No + Company � ' a
Y "Cortsfied copy is Hereby furnished-'qLOK
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
❑
Certified copy s filed with the county building inspection ADDRESS a Zt
r � department s r w NUMBER jr FIXTURE OR ITEM : @ w FEE R _ y
Do"
� i *1 ' LOCALITY
— K � Th � s WATER CLOSET(TOILET)
t Date Applicant a !NEAREST a„
CERTIFICATE OF EXEMPTION FROM WORKERS f ' J ; CROSS ST
t „ BATH TUB
�( COMPENSATION INSURANCE " a s SHOWER r OWNER t ri` f --S
(This sectionmeed not be completed if the work involved by ' MAIL
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the permit is for;one hundred dollars($100)or less) LAVATORY ADDRESS U
I certify that in the performance of theworkfor whichrthis per
mit s issued I shall not employ any person in anyimanner so u 'SINK r t CITY ` d TEL NO �)
as to!become subject to the Workers Compensation Laws of it
10 . - F ps, r DISHWASHERS CONTRACTOR 3 t a
Date t Applicant CLOTHES WASHER 6
k NOTICE TOAPPLICANTIf after mooing this Certificate of Ex t - ADDRESS Z '"
remption you should become subject to the Workers Compen s SWIMMING POOL RECEPTOR CITY -1 !l TEL NO cam'Z laryr
sation provisions of the Labor Code you must forthwith comp LAWN SPRINKLER SYSTEMot _i J11 AeD
a ly w th such provisions or this permit shall be deemed revok STATE t LIC
a ed - * ; t LICENSE NO 2 CLASS
t j WATER HEATER r t � �LICENSED CONTRACTORS DECLARATION e
r e , TRI Q/ ESSED BY� 1
the affirm that I am licensedunder prov s ons of Chapter GAS SYSTEM OUTLETS OY K
9(commencing with Sect on 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code and my I cense s n full force and of 5 PER SYSTEM
sect �r * DATEL �� Z� " VALIDATION a 4 h d
License Number L,c Class —ti O
ri a r" FIN x t
Contractor �TH ��Date (k' O
x ru y ,r < S. �
❑,I am exempt under Sed ` N r a t W
B 8P C for th s reason + ► t �` y
�. e > 4 Z
s t Date A v r(PLUMBING PERMIT ISSUING FEE$ r t r y
Signature r+� Qo*c k t t C
r n s J ^ , TOTAL FEE iJ a
a SINGLE FAMILY
x t s HOME OWNER BUILDER DECLARATION �'t Plan;heck applicant t,
I hereby off rm that I 11 am exempt from the Contractor s L cerise Nome tT s *' * ;-ACCT
g 4
Law for the following reason (Sect on 7031 5 Business and w a ? f iS a
Professions ,s60 �� O
aCode) r i '_t Address t ++ a
t❑r I as"ownerrof thetproperty w II do the work and the City t r �s f a Tel No t T \ r 1 ITEM3
t structure s not intended or offered for sale(Section 7044 « e
r Business and Professions Code) r r t ) t r a p TnTAL 22® 0
ti CONSTRUCTION LENDING AGENCY �` ++nn i
I hereby affirm that there is a construct on lending agency for F " :44 r t a r °
Wa
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the performance of the work for whichithis perm t is issued
(Sec 3097 G C ) b t'
s
Lender s Name 4 1 r 4 w ' 0000'€w1 fit 1116979
t
Lender s Address b s
,kI certify that I have read th s apps cation and state that the
above information is co rect I agree to comply with all County
ordinances and State laws regulating Plumbing and hereby S 1 1
authorize representat es of this County to enter upon the t
above mentioned property for nspection purposes
K s a I ' SEE REVERSE FOR EXPLANATORY LANGUAGe
Signature of Per rttee d Date
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