HomeMy Public PortalAbout5132TEMPLE CITY BLVD_Plumbing (2) • WORKERS'COMPENSATION DECLARATION DPW 4/87 APPLICATION FOR PLUMBING 'PERMIT '
I hereby affirm that I have a cemhcote of consent b self In- 7e> 7A
sure or a certificate of Workers Compensation Insurance or a CE 817(REV 8/86)
certified copy thereof (Sec 3800,•Lab C )
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No Company
Certified copy is hereby furnished r '
1 Candied ca is filed with the tours building m FOR APPLICANT TO FILL IN(PRINT OR TYPE BUILDING y�
copy county g spection ) ADDRESS s/3-1 l °t
department , ) • NUMBER FIXTURE OR ITEM ® FEE ` LOCALITY
' WATER CLOSET(TOILET) JU p1s'X
Date Applicant _ NEAREST
1 CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 661 CROSS ST
COMPENSATION INSURANCE SHOWER v OWNER r
_(This section need not be completed If the work Involved by- _ - - - - - - MAIL
thst permit Is for one hundred dollars ($100)or loss) LAVATORY ADDRESS S/,32 Temple Co. (}
I certify that in the performance of the work for which this per- SINK CITY 'TEL NO /
Toler-
m.1 is Issued I shall not employ any person in any manner so
as to become subject to the Workers Compensation Lows DISHWASHER /
r�
11 T CONTRACTOR
Date 9*-I`LP8 , + Applicant R,,k _1 i A 1C..0 CLOTHES WASHER
NOTICE APPLICANT If after making thin ADDRESS
Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITU ` TEl NO
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM `
ly with such provisions or this,permn shall be deemed revok- STATE LIC
ed WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION O DISTRICT NO PROCE BV
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER `J
U
fect Professions Code and my license is in full force and of 5 PER SYSTEM FINAL _ VALID ON 6
DATE
License Number Lit Class / —�
FIN cc
Contractor Dote - , BY O
1 am exempt under Sec ,� W
6
B 8P C for this reason Plan check fee _ ► NZ
Date - PLUMBING PERMIT ISSUING FEE$
Signature t`
TOTAL FEE 3 0 6 0 8 A
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant # e e'e e e 5
1 hereby affirm that I am exempt from the Contractor's License Nome
Law for the following reason (Section 7031 5 Business and ( • - 34.50
Professions Code) Address
I as`owner of the property will do the work and the City Tel No • • • 3 Q,5 05
structure Is not intended or offered for sale(Section 7044
' Business and Professions Code) , _ U q. 06'a 8 8
CONSTRUCTION LENDING AGENCY
I 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 ) `
Lenders Name
Lender's Address ,
I certify that I have read this application and state that the t
above mformatlon Is correct I agree to comply with all County
ordinances and State jaws regulating Plumbing and hereby
authorize representatives of this County to enter upon the '
above-mentions property for inspection purposes -
-& — _ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of PeVirnittee Date '