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Home My Public Portal About5349TEMPLE CITY BLVD_Plumbing (2) WORKERS COMPENSATION a c noN DECLARATION DPW APPLICATION FOR PLUMBING PERMIT I herb�iv affnm thpt I have a certificate of consent to self m- pmt z/� 4 I {ure L�erti ficato of Workers Compensation Insurance or a CE 81 7( U Pe � CE BI](REV B/86) � certified copy thereof (Sec 3800 Lob C ) ` L6 COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No Company�' e FT 4V Certified copy is hereby furnished Certified co is filed with the coup building ins FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDINGC copy county g pection DDRESSp/ C r (/ deportment NUMBER FIXTURE OR ITEM ® FEE LOCALIT DateI /�Ok7ApPlicant /sem•//.( C-I r i WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS S7ro COMPENSATION INSURANCE SHOWER �OWNER NAz44 (This section need not M completed If the work Involved by MAIL The permit Is for one hundred dollen($100)or INs ) LAVATORY ADDRESS - t G I certify that in the performance of the work for which this per- SINK, TEL mit is issued I shall not employ any person In any manner so CITY T as to become subject to the Workers Compensation Laws DISHWASHER v CONTRACTOR Dv Dote Applicant CLOTHES WASHER sty ADDRESS G NOTICE TO APPLICANT If after making this Certificate of Ex SWIMMING POOL RECEPTOR emption you should become subject to the Workers Compen CITY TEL N nation provisions of the Labor Code, you must forthwith comp LAWN SPRINKLER SYSTEM Ad ly with such provisions or this permit shall be deemed revok- STATE UC ed I WATER HEATER LICENSE NO CLASS ' LICENSED CONTRACTORS DECLARATION DISTRI PKVD BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS FJZ ti P /1 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER (/ wn and Professions Code and my license is in full force and ef- 5 PER SYSTEM FINAL VALID ION fact DATE d License Number L¢ Class FINAL QUf� Contractor Dote BY ) p • r ❑ I am exempt under Sec LL B 8P C for this reason Plan check fee ' ► Dote PLUMBING PERMIT ISSUING FEE$ 170 A Signature TOTAL FEE 81 3 3 A SINGLE FAMILY HOME OWNER BUILDER DECLARATION Plan check applicant # • • • •I. 5 I hereby affirm that I am exempt from the Contractor s License Name ) • • r2 a 55 0 Law for the following reason (Section 7031 5 Business and Professions Code) Address ❑ f •.• • 2850 I as owner of the property, will do the work and the Cny Tel No structure is not intended or offered far sale(Section 7044 Business and Professions Code) r, ( Q11 b 8 7 CONSTRUCTION LENDING AGENCY - I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ C ) Lender s Name Lender s Address I certify that I have read this application and state that the , above Informo on Is correct I agree to comply with all County ordinances State lows regulating Plumbing, and hereby authorize esentatives of this County to enter upon the , above Io pro y Inspection purposes ^� SEE REVERSE FOR EXPLANATORY LANGUAGE m Date