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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