HomeMy Public PortalAbout5232TEMPLE CITY BLVD_Plumbing WORKERS'at I have a ION DECLARATION eE81774A667AAPPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent fb self ce m Ix-sol
insure, or a certificate of Workers'Compensation Insuranpe,or
a certified copy thereof,(Sec. 3800,Lab.C4,
Policy No.i Company _
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby fur:eco
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
® ADDRESS - -
Cert)fiedi rnp) is File with tuntgiBEH FIXTURE OR ITEM • FEE
LOCALITY._ WATER CLOSET
Date Atplica NEAREST
BATH T ': ., CROSS ST.
CERTIFI XEMPTION FROM WORKERS' , >
O SATION INSURANCE SHOWER OWNER - U
(This section need not be completed if the work involved LAVATORY MAIL WADDRESS - _J
by the permit is for one hundred dollars (SIoO) or less.) SINK CITY ., TEL. NO.. 1 LL
I certify that in the performance of the work for which this DISHWASHER ?
permit is issued, I shall not employ any person in any manner .) - CONTRACTOR .. cc
sq as to become subject to the Workers' Compensation Laws. CLOTHES WASHER ADDRESS *-`- _. cc
Date Applicant SWIMMING POOL RECEPTOR d
NOTICE TO APPLICANT: If, after making this Certificate of CITY .. TEL. NO. 0.
STATE LIC.
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM 141�// W
Compensation provisions of the Labor Code, you must forth- WATER HEATER LICENSE NO. - LIC. / /� ~
with comply with such provisions or this permit shall be
deemed revoked. -GAS SYSTEM OUTLETS �p
Dl! lCT 6 NO, PRCES$ED DY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi. FINAL VALIDATION
ness and Professions Code, and my license is in full force and DATE
effect.
FINAL
License Number
Lie.Class BY
ContractorDate
0 1 am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
Lie.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section 7031.5, Busi- City - Tel.No. ):
ness and Professions Code): ;
I] 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(Section 7044, Business and Professions Code). .. .- ... -0 19 VX A
CONSTRUCTION LENDING AGENCY ,a a.e e S
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is fs
issued(Sec.3097,Civ.C.). p e Is Q`'
Lender's Name
1 Lender's Address
I certify that 1 have read this application and state that the
above information is correct. I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE ,
ordinances and State laws regulating Plumbing, and hereby i
authorize represe ves o ounty to enter upon the /
above-mention property forinspe ion purposes.
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L
Sigd6tdte of Permittee Date