HomeMy Public PortalAbout4802 ALESSANDRO AVE_Plumbing_5/25/1982_water heater WORKERS'COMPENSATION DECLARATION 78A887A APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self ce eii (z eo)
insure, or a certificate of Workers'Compensation Insurance or CITY OF TEMPLE CITY
a certified copy thereof(Sec 3800 Lab C)
Policy No 201 916 Company SrTF 16898
COUNTY OF LOS ANGELES UILDING AND SAFETY
Certified copy is hereby furnished l� FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS 4802 Alessandro
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE
department WATER CLOSET LOCALITY Temple Cit
Date4 /1 /89 ApplicantG..enera l InRta drat 3.cn NEAREST
BATH TUB CROSS ST Lower Azusa
'CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER J. Barnes
(This section need not be completed if the work involved ILAVATORY MAIL >-
ADDRESS same 9L
by the permit is for one hundred dollars ($100) or less)
)
I certify that in the performance of the work for which this DISHWASHER Xpermit is issued, I shall not employ any person in any manner CONTRACTOR General Installation Q
so as to become subject to the Workers' Compensation Laws CLOTHES WASHER ADDRESS 6558 West 61Vd. U
Date-App,licant W
SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT If after making this Certificate of CITYLOS Angeles TEL No753-254 ran
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM _ Z
LIC
Compensation provisions of the Labor Code, you must forth •00 LICENSE NO 15183 9 CLASS 36
with comply with such provisions or this permit shall be ] WATER HEATER
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO O CEIgSED B
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I'am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi FINAL VALIDATION
ness and Professions Code, and my license is in full force and DATE
effect l
License Number 151839 Lic Class C36 FINAL
BY
ContractorW'O•Provin Date 4/5/55 V
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
i acting in my professional capacity (Section 7051 Bus
mess and Professions Code) TOTAL FEE •55 0 t
Lic or Reg No Date Plan check applicant
i
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address 3 0 7 7 A
License Law for the following reason (Section 7b31 5 Busi City Tel No
ness and Professions Code) # o a o o o 5
I, as owner of the property am exclusively contracting
with licensed contractors to construct the projectf 2 0 0 1 2 5 0
(Section 7044, Business and Professions Code)
i
CONSTRUCTION LENDING AGENCY o o� 1 2 5 0
I hereby affirm that there is a construction lending agency 0 212 5—8 2
for the performance of the work for which this permit is
issued(Sec 3097,Civ C)
Lender's Name
Lender's Address
i
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 iLANGUAGE
ordinances and State laws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above mentioned property for inspection purposes
Signature of Permittee Date