HomeMy Public PortalAbout5403TEMPLE CITY BLVD_Plumbing (2) WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING .PERMIT
I hfreby affirm that I have a certificate offconsent to self m- 77ADPW'
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sure,ora certificate of Worken'Compbnsatton Insurance ora CE 817(REV 8/86) 4
certified copy thereof (Sec 3600, Lab C )
Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
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Certified ecropy q filed with the count'building g inspection NUMBER FIXTURE OR ITEM @ FEE
7� LocAlrry
Data/ L 2� Applicant s' CN ii WATER CLOSET(TOILET) NEAREST ;
r CERTIFICATE OF EXEMPTION FROM WORKERS
BATH TUB CROSS ST 0(-(V/c-
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LF✓G, COMPENSATION INSURANCE SHOWER _ _ OWNER
(This section need net be completed IF the work Involved by MAILBL
the permd Is For one hundred dollars($100)or less ) LAVATORY ADDRESS
I certify that in the performance of the work for which this per SINK CITY - TEL
mit is Issued, I shall not employ any Person in any manner so
as to become subject to the Workers'Compensation Lows DISHWASHER `
' CONTRACTOR S ,
Date-Applicant a CLOTHES WASHER
NOTICE TO APPLICANT If after making this Certificate of Ex ADDRESS r
emption you should become subject to the Workers'Compen SWIMMING POOL RECEPTOR f
sotion provisions of the Labor Code CITY TEL NO
p you must forthwith camp LAWN SPRINKLER SYSTEM '
ly with such provisions or this permit shall be deemed revok STATE LHC ,
ed WATER HEATER LICENSE NO CLASS r
LICENSED CONTRACTORS DECLARATION ,QI$TRHq tip./ ROLE Y -
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS c(/1 U VX
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER /
( LI
and Professions Code and my license is in full force and of 5 PER SYSTEM } FINAL ADATION `y
DATE
License Number Llc Class 0 0
FINALcc
Contractor Date BY r 10
I am exempt under Sec Lust
B&P C for this reason Plan check foe 33► z
Date PLUMBING PERMIT ISSUING FEE$ / `
Signature TOTAL FEE -
SINGLE FAMILY C'
HOME OWNER-BUILDER DECLARATION Plan check applicant '
•
I hereby affirm that I am exempt from the Contractor s License Nome ACCT'T
Law for the following reason (Section 7031 5 Business and �n-t l�r
Professions Code) Address 3301 e
50
10/ I, as owner of the property, will do the work and the City Tel No 1 ITEMS
structure is not intended or offered for sale(Section 70" - TOTAL 16 d
Business and Professions Code) '
CONSTRUCTION LENDING AGENCY ' 00K 16.5[1.�
I hereby affirm that there is a construction lending agency for
the Performance of the work for which this permit-is issued . d
CHAWE
(Sec 3D97 Civ C )
Lender is Name ; ` D 12/27'89
777$ 1 API V•20
Lender s Address
I certify that I have read this application and state that the ,
above Information is correct I agree to comply with oil County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
a e-mentione property for inspection purposes _ -
L i z7 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee - Dote