HomeMy Public PortalAbout5319TEMPLE CITY BLVD_Plumbing (2) WORKERS affirmCQNM c TION DECLARATION 04 A APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that hove aveertdlcatpso(edhseTt to self m- 10-00x '4197
sure or a certificate of Workers Compen n Insuregce or a CE 8I7(REV B/Be)
certi�d tn4r�c 381
8 Lab /J '
Pith Com COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS i
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy m filed with th county building inspection NUMBER FI ADDRESS
pa ent %TORE OR ITEM FEE h3
[J/d� /J LOCALITY
Date �� 7 Applic WATER CLOSET (TOILET) �y'� SD
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB gTef Yrs CROSSST
COMPENSATION INSURANCESHOWER ,sp OWNE
(This section need not be comPleted If the work Involved by MAIL
the Pontiff Is for arse hundred dollars (6100)or less) s LAVATORY SaS ADDRESS
'I certify that In the performance of the work for which this per /L
mit is Issued, I shall not employ any person In any manner so SINK Oo CITY TEL
as to become subject to the Workers Compensation Laws DISHWASHER ,$'O
CON
TRAC i
Date AppI cont CLOTHES WASHER ,sG
NOTICE TO APPLICANT If after making this Certificate of Ex ADDRESS—
DDRESS l!
emption you should become subject to the Workers Compen- SWIMMING POOL RECEPTOR _�
r
CITY
sation provisions of the Labor Code you must Forthwith comp LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok STATE LIC �% 2 ;
ed WATER HEATER S LICENSE NO �Y�
LICENSED CONTRACTORS DECLARATION DISTRICT NO ESSED BV
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS •SO
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER Oe
and Professions Code and my license is in full fog,f a ef- 5 PER SYSTEM FINAL /J VALIDATION >'
feet
License Number LIc Class DAff S
O
FINAL U
Q
Contract � Dy(�/�'� BY O
❑ I am exempt under Sec W
8 8P C for this reason y
Plan check fee Poo.
PLUMBING PERMIT ISSUING FEES `
Signature
TOTf�
SINGLE FAMILY Plan check applicant 3307 172.50
ROME OWNER BUILDER DECLARATION PP
1 hereby affirm that I am exempt from the Contractor s License Name 1 ITEMS
Low for the following reason (Section 7031 5, Business and TOTAL 172
Professions Code) 'address TOTA -rte
.50
I as owner of the property will do the work and the City Tel No DECK 172.5[1
structureis not Intended or offered for sale(Section 7044 CKA14E •00
Business and Professions Code) ► 4fRaVG
CONSTRUCTION'LENDING AGENCY '
1 hereby affirm that there is a construction lending agency for 1 1/ 4/91I
the performance of the work for which this permit Is issued GAhNI 1 {,�:
Sec 3097 Civ C 12
Lender s Name
Lender s Address
I certify that I hove read this application and state that the
above information is correct I agree to comply with all County ►
ordinances and State lows regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
a ve men�77.pert' for inspection purposes a
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date '