HomeMy Public PortalAbout5313TEMPLE CITY BLVD_Plumbing (2) • WORKERS COMPENSATION DECLARATION - APPLICATION FOR PLUMBING PERMIT '� I
L I hereby, 6nm that I have a certificate of consent to self 76A667A - ILJI
nsu;e or a certificate of Workers Compensation Insurance CE W7(REV 10/81)
`or a certified copy thereof(Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company -
Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) 1-3_ _ BUILDING
Cernhed copy is filed with the county building mspec ADDRESS _
tion department NUMBER FIXTURE OR ITEM ® FEE
LOCALITY
WATER CLOSET
Date Apphgont NEAREST W t
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB - - CROSS ST -
COMPENSATION INSURANCE OWNER
(This section need not be completed B the work Involved by SHOWER
so e-
the permit is for one hundred dollars ($160)or Ips ) LAVATORY MAIL
ADDRESS
' I certify that in the performance of the work for which this �
permit is issued I shall not employ any person in apy manner SINK CITY TEL NO _
to as to become subject to the Workers Compen Ghon Laws DISHWASHER _ _
��,,,, ..��--yy �jj1��� - CONTRACTOR
DoleL�Applicont L CLOTHES WASHER
NOTICE TO APPLICANT If after making this Certificate of ADDRESS _
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth CITY - TEL NO
with comply with such provisions cr this permit shall be LAWN SYSTEM STATE
K
deemed revoked i WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION _ -DISTRICT - PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS Q ,
(commenungwth Section 7000) of Division 3 of the Business OUTLETS OVER
and Professlom Code and my license is in full force and effect 5 PER SYSTEM FINAL _ 7--� VALIDATION
License Number tic Class _ DATE
FI 8
Contractor Date BY
13 I am exempt under Sec O
B$P C for this reason ' I U
Plan check fee ,
Dote I PLUMBING PERMIT ISSUING FEE f /U 5 7 4.4 A
Signature
TOTAL FEE # e e is e e 5
Plan check applicant 1 - - 1650
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name - e e e 16506
1 hereby affirm that I am exempt from the Contractor's License '
Law for the following reason (Section 7031 5 Business and Address
Professions Code) City _ Tel No
1, as owner of the property will do the work and the
structure is not intended or offered for sale (Section ,
70" Business and Professions Code) - - - -
• CONSTRUCTION LENDING AGENCY _
I hereby affirm that there iso construction lending agency for
the performance of the work for which this permit is issued
(Sec 3097 Cry C )
Lenders Name--
Lender s
ome Lenders 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 Sto a lows regulatmg•Plumbing, and hereby _ 27
authorize repre3e natives of this County to enter upon the
abo enhon property for inspection purposes '
SEE REVERSE FOR EXPLANATORY IANGUAGE-
/D —�3- &
Signature of Permittee Date — - - -� - - — - — -- ' ' '