HomeMy Public PortalAbout5002TEMPLE CITY BLVD_Plumbing DECLARATI
WORKER I have a certificate
at consent to 7eAW7A APPLICATION FOR PLUMBING PERMIT ll
I hereby affirm that I have a cenlhcete of consent to Bell Insure _
or a cenihcete of Worker s Compensation Insurance or a certified 1 _
copy thereof(Seo 3800 Lab C)
PaDm' ro COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
❑
Certified ropy is hereby lurMnhetl GADO ES�e 2 A.
❑ Cemhed copy is filed with the court W dd I FOR APPLICANT TO FILL IN(PRINT OR TYPE)
ry kq Inspection r I
department NUMBER FIXTURE OR ITEM ® FEE LOCALITY � !
Date U Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST
BATH TUB
COMPENSATION INSURANCE ASSESSOR
MAP BOOK PAGE PARCEL
(This aaollon need not be completed If the work Involved by the SHOWER
psrmil to for one hundred doltan($100)or leu) OWNER
I certify that in the performance of the work for which this permit LAVATORY - S j
Is Issued I Shall not employ any person In any manner eo as to ' 61NX Q MAILADDFOOL N• /� . / r
become subject to the Workers Compensation Laws
DISWASHER CITY C TEL SV,
Date Applicant CLOTHES WASHER /37 QO CONTRACTOR
NOTICE TO APPLICANT If after making this Certificate of
Exemption you should become Subject to the Workers'Compensation SWIMMING POOL RECEPTOR
pronsmne of the Labor Code you must forthwith comply with such ADDRESS
pronsions or this permit Shall be deemed revoked LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION WATER HEATER CITY TEL NO d
I hereby affirm that I am licensed under provisions of Chapter g
(commencing With Section 7000) of Division 3 of the Business and M STATE LIC 0
Professions Code and my license Is in full force and effect ' GAS Sy" OUTLETS vV LICENSE NO CLASS
OUTLETS OVER DISTRICT HOBV cc
a PER SYSTEM O
License Number Llc Clam w.A'f 0"o r O V
FlNAL
DATE z— 25''1VAUP&TIO3 —" a
Contractor Dere _
❑ I am exempt under Sec BY3307 100.65 z
iB sP C for this reason Trrka 1 I 1[J 1.�
Date Plan check fee ►
TOT
PLUMBING PERMIT ISSUING FEE$ Z C 100 .65
Slgnetva GFECK 100.65
❑ TOTAL FEE / .011
SINGLE FAMILY Plan Check applicant CHAKE
HOME OWNER BUILDER DECLARATION Name non _
I hereby affirm that I am exempt from the Contractor• License Law - M-0001 2124/9
far the following reason (Section 7031 5 Business and Professions Address
Code)
Gry Tel No $340 1 AM 9:411
1 as owner of the property will do the Werk and the structure
is not intended or offered for Sale(Section 7044 Business '
and Professions Catle)
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the
performance of the work for which this permit la Issued (Sec 3D87
CIv C)
Lander a Name
Lender a Address
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
representatives of this C unty to enter upon the above-mentioned
Riopan Sri . eco urposm SEE REVERSE FOR EXPLANATORY LANGUAGE
e 61 Permittee - Date