HomeMy Public PortalAbout4522TEMPLE CITY BLVD_Plumbing (2) WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 74AAe7A
insure or a certificate of Workers' Compensation Insurance CE 817(REV 10/81)
or a certified copy`thereof (Sec 3800, Lab C ) COUNTY OF LOS ANGELES ' ' BUILDING AND SAFETY
Policy N.Q2A LComponyT'
ViT �O
wtified copy is hereby furrtrshed
Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN(PRIM OR TYPE)
NUMBER FIXTURE OR ITEM ® FEE
tion department
LOCALITY
Data WATER CLOSET
AppMPTI CROS ST Lowc c!S
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH NB
COMPENSATION INSURANCE OWNER
(This section need not be completed R the work Involved by SHOWER
the permh Is for one hundred dollars(1111100)or leu) MAIL
I certify that m The performance of the work for which this ADDRESS
permit is issued I shall not employ any person in any manner SINK CITY TEL NO
so as to become subject to the Workers Compensation Laws
DISHWASHER CONTRACTOR � � Sr—
Date Applicant CLOTHES WASHER I'
NOTICE TO APPLICANT If, after making this Certificate of ADDRESS l.)� /�S �!V
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM Cli� • TEL NC SYs—�a
with comply with such provisions or this permit shall be STATE LIC /
deemed revoked WATER HEATER LICENSE NO d CUSS 3.E7
LICENSED CONTRACTORS DECLARATION DISTRICT NO SSED By
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUT1ETSOVER iQ y
and Profes iam Cade[and my license is in full force and effect 5 PER SYSTEM FINAL �J+� Q VALIDATION o.
License Number 7 00/b Lic Class bl 36-
DATE �"GC/ @� V
FINAL
Connector ZL16'cICG( Date 7 F.
❑ I am exempt under Sac �O 7 / d
B 8P C for this reason ` / N
Plan check fee =
Dara PLUMBING PERMIT ISSUING FEE f O 0 P383. 1 A
Signature
' TOTAL FEE �p O
SINGLE FAMILY
Plan check applicant .2 - - 1650
HOME OWNER-BUILDER DECLARATION Name s e e ) 6 5 0 5
1 hereby affirm that I am exempt from the Contractor's License i
Law for the following reason (Section 7031 5, Business and Address
Professions Code) City Tel No
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section pop
Business and Professions Code)
CONSTRUCTION LENDING AGENCY
1 hereby off um that there is a construction lending agency for -
the performance of the work for which this permit is issued
(Sec 3097, Civ C )
Lender s Name
Lender s Address
I certify that I have read this application and state that the ►
above information is correct I agree to comply with oil County
ordinances and State jaws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee pare