HomeMy Public PortalAbout5312TEMPLE CITY BLVD_Plumbing (2) WORKERS'COMPENSATION DECLARATION ,axana I�
1 hereby affirm that I have a certificate of consent to ,elf ca .I, ,a-.a) APPLICATION FOR PLUMBING PERMIT a
insurer or a certificate of Workers'Compensation Insurance,or
a certified c y ther o 00,Lab y� / LLL...III
`Derr///�`r`p��y COUNTY OF LOS ANGELES T/ �� BUILDING AND SAFETY ,
Pp1ncy N parry '
rtifted copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ertified co ER FIXTURE OR ITEM PEE ADDRE
copy with the my In ms t
nt LOCALITY
WATER CLOSET
a pplicant NEAREST
CERTIFICATE EXEMPTAN FROM WORKERS' BATH TUB CROSS ST G
COMPENSATION INSURANCE SHOWER OWN G
LAVATORY MAIL
(This section iced not be hndredcompleted ll the work omotvedr less) ADDRESS
by the permit U for one hundred QoBafs ($100) m less) SINK CITYJ61TC41 TEL NO B�
I certify that in the performance of the work for which this DISHWASHER CONTRACTOR
permit a Issued, 1 shall not employ any person in any manner O
so as to become subject to the Workers Compensation Laws CLOTHES WASHER ADDRESS Ur
Date Applicant SWIMMING POOL RECEPTOR W
NOTICE TO APPLICANT If, after making this Certificate of CITY Z" TEL NO 7
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM
6TATE LIC
Compensation provuslons of the Labor Code you must forth WATER HEATER LICENSE NO Q CLASS
with comply with such provusiom or thus permit shall be
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO PR ESSED_B
-
LICENSED CONTRACTORS DECLARATION OUTLETS OVER -�a
1 hereby affirm that I am licensed under provanons of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busl FINAL VALIDATION
nese and Professions Code, and my license is in full force and DATE /[/ ��j
effect
FINAL
License Num er ss BY
Contrectoe
I am exempt from the licensing requirements as 1 am a Plan Check fee f,;� '
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus
men and Professions Code) TOTAL FEE
Lie or Reg No Date Plan check applicant
HOME OWNER BUILDER DECLARATION Name
1 hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section 7031 5 Busi Clty Tel No 2 1 ,6 18 A
nese and Professions Code) a a • • • 51, as owner of the property, am axclusrvely contracting
with licensed contractors to construct the project
(Section 7044, Busmess and Professions Code) Q a 0,1000
CONSTRUCTION LENDING AGENCY • a e 1 (ZOO 5
1 hereby affirm that there us a construction lending agency
for the performance of the work for which this permit is
vaned (Sec 3097,Civ C)
Lender's Name
Lender's Address
I certify that I have read thus application and state that the
above information Is correct I agree to comply with all County _ SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and to regulating Plumbing, and hereby
autho ze rept at s of this County t enter upon the _
eb enno pr ty for inepectio r ses0
/' Sagliffiti,re of Fermittee Dat