HomeMy Public PortalAbout4505TEMPLE CITY BLVD_Plumbing (2) WORKERS COave a c TIONDECLconseN APPLICATION FOR PLUMBING PERMIT
'j a�rm•ihef I have a cepimpen at o consent to self m_ 764667 DPW 4]87 /1
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sures arc copy
6 re of Workers Lob Csobon Insurance oro CE By(REV Bi86)
certified copy thereof (Sec mp8CO Lab C ) - COUNTY OF LOS ANGELES DEPT _OF,PUBLIC WORKS
Potyy No Company t _
` Certified copy is hereby furnished FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING D , ' 'I�
Certified copy is filed with the county budding inspection ADDRESS H3 � "TE fY1 PI6 CIT% O/
^ deportment I NUMBER FIXTURE OR ITEM FEE
� LOCALITY
Date Applicant ,/ N
/ WATER CLOSET(TOILET) 30 ,
EAREST
CERTIFICATE OF EXEMPTION FROM WORKERS �, BATH TUB b DO CRO55 ST \f) +
COMPENSATION INSURANCE 3 SHOWER D OWNER P�T�p(,s 'a i'tf 1�Q `
(This section naafi not be completed If the work Involved by
the permit Is for one hundred dollars($100)or Ins ) LAVATORY MAIL
ADDRESS "tel �F
1 certify that in the performance of the work for which this per TEL NO SINK CITY
ir
mit is issued I shall not employ any person in any manner so G L111%_3�7
as to become subject to the Workers Compensation Laws DISHWASHER
- - CONTRACTOR
• Date Applicant CLOTHES WASHER ADDRESS
,
NOTICE TO APPLICANT If, offer making this Certificate of Ex SWIMMING POOL RECEPTOR
empbon you should become subject to the Workers Compen- CITY TEL NO
sation provisions of the Labor Code you must forthwith comp LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok STATE LIC
ed WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter I GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER a
and Professions Code and my license is in full force and of 5 PER SYSTEM 4
FINAL VALIDATION Y
fect DATE r Ii
License Number Lic Class C
FINAL V
Contractor Date BY Q
# O
I am exempt under Sec
B 8P C for this reason, , a ,A � W
Plan check fee
Date PLUMBING PERMIT ISSUING FEES
' Signature
TOTAL FEEor 6; _470 o
SINGLE FAMILY - Plan check applicant
HOME OWNER-BUILDER DECLARATIONr}
1 hereby affirm that I am exempt from the Contractor a License Name i• -
Low for the following reason (Section 7031 5 Business and ALIT.i
Professions Code) Address
.l .i317 tn.51I
® I as owner of the property, will do the work and the City Tel No 1 ITEMS
is not intend44 ed or offered for sole(Section 70 r ,
Business and Professions Code i T
TOTAL 125 -!TO
CONSTRUCTION LENDING AGENCY ` , �HEi.r 1,,1.
I hereby off um that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec 3097, Ctv C )
Lender s Name r 1XIM-lIG01 5/ 8/51
Lender s Address 6339 1 AM 10:21
I certify that I have read this application and state that the 11111's
above information is correct I agree to comply with all County
ordinances and State lows regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above m ntioned property for inspection purposes i
o / -4--- SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o Perminee ' Date