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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 '