HomeMy Public PortalAbout4442TEMPLE CITY BLVD_Plumbing (2) WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hc4eby affirm that I have a certificate of consent to self 200028 DPW 8/87
insure ce a certificate of Workers Compensation Insurance, 76AS67A
or a certified copy thereof (Sec 3800, lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
P❑ol icy No Company
Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING '
Certifiedcopy is bled with the county buildingmspet- ADDRESS
nd
on department NUMBER FIXTURE OR ITEM ®J FEE LOCALITY
Date Applicant WATER CLOSET , / NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROu ST
COMPENSATION INSURANCESfitSWER- D OWNER i
(This section need not be completed If the work Involved'by MAIL
the pennff Is for one hundred dollars (5100)or less) LAVATORY ADDItE55 .01
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, E TEL NO
W as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR IF
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT If after making this Certificate of ADDRESS
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL NO
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO CUSS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby offum that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS _ !��
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER v
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL VALIDATION'
Li<enae Number Lic Clau DATE U
FINAL
Contractor Date BY Fpd'
❑ I am exempt under Sec yU1s��
B 8P C for this reason Plan check fee Z
Dote
PLUMBING PERMIT ISSUING FEES � !C -
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY ;
HOME OWNER-BUILDER DECLARATION Name Ay{i r
I hereby affirm that I am exempt from the Contractor s License Address
TV
Low fa the fallowing reason (Section 7031 5, Mu ss and [4,yli
Pr ions Code) 'tom`/���� '/; %`rld City Tel No iw
I as owner of!he property, will do the k and the 1 ITEMO
structure is not intended or offered for sole (Section ► TI]}A� _ �
7044, Business and Professions Code) '
' CONSTRUCTION LENDING AGENCY CASH
1 hereby affirm that there is a construction lending agency for I- .UU
the performance of the work for which this permit is issued
(Sec 3097, Civ C )
Lender's Name 10/11(41
Lender s Address 9443 1 AN -:-C
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 reprelentatives of this County to enter upon the
above mentioned property for mapechoryryry Irpoaes "
tyC�� SEE REVERSE FOR EXPLANATORY LANGUAGE
Si oture of Permittee Date