HomeMy Public PortalAbout5349TEMPLE CITY BLVD_Plumbing t �
6rwoaRscoMPENSAncrioconn20-01�B/� APPLICATION FOR PLUMBING PERMIT
IcheDy off that at I hta vecertificate offconseseto consent to Bell insure _ -
or a 4ertiflcpta of Worker a Compensation Insurance or a certlfled 'e t
copy ther
leof(Sec 3800 Lab C) '
put,Noil,g9�L27-%", tYi-A-TE k)t,)Q COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUB4IC WORKS DIV
❑ Cerbli le her " •` �M
COPY hereby furnished 3t t
�r / FOR APPLICANT TO FILL IN(PRINT OR TYPE) pOREBS ILDING �
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Ce etl copy 4 hied with the county bulkk Im
de �� NUMBER FIXTURE OR NEM O FEE LOCALITY
Data Applkenl WATER CLOSET NEAREST n `
CERTIFICATE OF EXCROSS ST
COMPENSATION
FROM WORKERS BATH TUB _
MPENSATION IN SURAN CE ASSESSOR
MABOOK� PAflE(.YJ PAACE✓y�
(Thu section need not be completed If the work Involved by the SHOWER
Psi Is for one hundred dollars($100)or MN) LAVATORY OWNER AtP-2v
I certify that in the performance of the work for which this permit
le issued I shall not employ any person in any manner iso as to SINK ADDRESS Q
become subject to the Workers Compensation Lewy
OMWASNER , CT' - TEL NO
Dole—NOTICE TO APPLICANT If icaifter making this Certificate of CLOTHES WASHER CONTRACTOR IVT Asso/—,
Exemption you should became subject to the Workers Compensation SWIMMING POOL RECEPTOR aa
provisions or this Permit provisions of the Labor shall be deemed de you must l evoked orthwith comply with such LAWN SPRINKLER SYSTEM
ADDRESS ..JZ
LICENSED CONTRACTORS DECLARATION CITY �A p TEL NO O d
I hereby affirm that I em licensed under provisions of Chapter 9 WATER NEATER
(commencing with Section 7000) of Dlween 3 of the Business and STATE /'vo LIC O
Professions Code and my license Is In full force and effect I OAS SYSTEM OUTLETS L�Efl9E NO ! C� 8
DISTRICT NO ED BY O
lumrrm Number A g0°I Lk: class 5 5 PER
OUTLETS� o : r i �F—
VALIDATION�yE
ContractAsisci . Date lzp W
va!
❑ I aexempt under Sec FINAL Z
m
B AP C for this reason
p Plan check fee
Signet II 1 t PLUMBING PERMIT ISSUING FEES 0 1J�/ Poo.
❑ TOTAL FEE [ D
SINGLE FAMILY Plan check applicant `
A '^
HOME OWNER BUILDER DECLARATION Name I tJTp IJ �V
I hereby affirm that I em exempt from thehe Contractor a license Law - -- � - AGGT.4
for the following reason (Section 7031 5 Business and Professions Address 1?, �(Jj pJJ
Cosa) o Ih 43.471)
❑ 5 IOq
I as owner of the property will do me work and the structure City Tel No �7 1 ITEMS
Is not Intended or offered for eels(Section 7044 Business
and Professions Code) , TOTAL '43 . 0101
CONSTRUCTION LENDING AGENCY CHECK AtS.GRI
I hereby affirm that there Is a construction lending agency for the
performance of the work for which this permit is issued(Sec 3097, - •117
Cm C)
Lender s Name r •- ODDD-000 1 91 7911
Lentler's Address 2773 1 ANI D 28
1 certify that I have reed this application and state that the above Pol.
Is correct I agree to comply with all County ordinances
and State laws regulating Plumbing and hereby authorize •- - ,
representatives of this County to enter upon the above mentioned
properly for Inspection purposes t BEE REVERSE FOR EXPLANATORY LANGUAGE ^