HomeMy Public PortalAbout4829TEMPLE CITY BLVD_Plumbing (2) WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 200026 DPW 6B7
insure or a certificate of Worker Compensation Insurance 7BA667A CITY OF TEMPLE CITY lul
ar a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS '
Pol icy No 6969_00"ny ' NMTr . r _
❑ .
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRIM OR TYPE) BUILDING
® SS —
Cerofmd copy s filed with the county buildingmADDRESS ADDRESS
tion department I NUMBER FIXTURE OR ITEM ® Fff LOCALITY
Date A /1 /a 2
— --rr9 pP S WATER CLOSET
7 A h a i NEAREST
r CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS S7
COMPENSATION INSURANCE _ I OWNER
(This section need not be completed If the work Involv;d by SHOWER
the permit Is for one hundred dollars ($100)or Ins ) LAVATORY MAR
ADDRESS
I certify that in the performance sof the work for which the 4029 T99AP10 QtY E1114 #E
permit is Issued, I shall not employ any person in any manner SINK CITU
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so as to become subject to the Workers'Compensation Lows — _
DISHWASHER CONTRACTOR
Dote Applicant CLOTHES WASHER • ADDRESS
NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR
Exemption you should become subject to the Workers' CITY TEL NO
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEMLes
with comply with such provisions or this permit shall be STATE Leles IC
deemed revoked I WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION 3 1 DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 i GAS SYSTEM OUTLETS
(commencing with Section 70001 of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is In full force and effect 5 PER SYSTEM FINAL VALIDATION
p
License Number 1 51 839 Lic Class 3 6 DATE C�
FINAL
VILV
Confractor HT-s�a }1Eerrt{} Date 9'� FI
❑ I am exempt under Sec lip
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B 8P C for this reason Plan check fee �blf/ alp V u�
Dare PLUMBING PERMIT ISSUING FEE f Z
Signature r s
TOTAL FEE
SINGLE FAMILY
Plan check applicant iC
r,- a
HOME OWNER-BUILDER DECLARATION Name ��-T•�
1 hereby affirm that I am exempt from the Contractor's License Add
res _�L] 7'1.--3
for the following reason (Section 7031 5 Business and 1 1
Professions Code) City Tel Na
❑ I as owner of the property will do the work and the T131AL 39 . 30
structure is not intended or offered for sale (Section
7044, Business and Professions Code) pop. NEC 1, 3Q.; l
CONSTRUCTION LENDING AGENCY LF�i-E
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued _ ,
(Sec 3097 Civ C ) r r_ n
�rKLi �rcii 1� 317�
Lenders Nome 13339 1 AN 2:4-,
' s r
Lender s Address -
I certify that I have read this application and state that the - ►
obove'formation is correct I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize repre3entativn of this County to enter upon the
above men one r0 ert inspection purposes i
�j� p p p / SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permdt i Date 91