HomeMy Public PortalAbout4520TEMPLE CITY BLVD_Plumbing (2) Worm that
Ihave COMPENSATION DECLARATIONcorse APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a cerhfimte of consent to self 7y�ye7q
msure or a certificate of Workers Compensation Insurance CE 817(REV 10/81)
or a certified cop hereof(Sac 3800, Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N Compony tde&r ,
Certified copy is hereby fumuhed❑ BUILDING FOR APPLICANT TO FILL IN(PRIM OR
Certified Copy is filed with the county building tnspec ADDRESS /-Sao NUMBER FIXTURE OR ITEM �_
hon department ® FEE LOCALITY I�
Dale Appli4ant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OVO4ER
(This section need not be completed N the work Involved by
the permMon
it is for one hundred dollars(5100)or less ) LAVATORY MAILADDRESS
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 sublect to the Workers Compensation Laws DISHWASHER /l z
CONTRACTOR _1 O
� Cl1A 0119,1 fif
Dote Applicant CLOTHES WASHER «s �-
NOTICE TO APPLICANT If, after making this Certificate of ADDRESS ) OSS '— t LA#J
Exemption, you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth- CITY r� TEL PIO
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE UO
deemed revoked WATER HEATER LICENSE NO Z140 0 CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby off um that I am licensed under provisions of Chapter 9 f GAS SYSTEM OUTLETS
(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 �.z� VALIDATION 6
a b J? v
License Number L¢ ClassDATE tY
FINAL _ t O
Contractor Dote BY
❑ W
I am exempt under Sec 6
N
B 8P C for this reason ?
Plan check fee
Date
PLUMBING PERMIT ISSUING FEE f
$Ignotura
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License —93790A
Law for the following reason (Section 7031 5, Business and Address
Profesmons Code) Cly Tel No ,# e s e e e 5
❑ I as owner of the property, will do the work and the , 2 • • 1650
structure is not intended or offered for sale (Section ,
7044 Business and Professions Code) 16505
e+ s
CONSTRUCTION LENDING AGENCY o 7. 1 9-83
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 Cw C )
Lender's Name
Lender s Address
I certify that I have read this application and state that the ►
above mformot�on is correct I agree to comply with all Count '
ordinances and State lows regulating Plumbing, and hereby
authorize repro tatives of this County to enter upon the
alio mentio pro r mspechan Pur mos
` SEE REVERSE FOR EXPLANATORY LANGUAGE
ig alure of Permee e ,