HomeMy Public PortalAbout5441TEMPLE CITY BLVD_Plumbing (2) 4--c
IMER3 COMPENSATION DECLARATION I DRY 9/119 - — -I hereby a ihet.l have a certificate of consent to self Insure '°"�'" APPLICATION FOR PLUMBING PERMIT - ILII
or a tartrate of Worker a Compensation I psurance or a certified
copy thereof(Se! 3900 Lab C)
' k COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
Policy No 1 Company -
❑ Certified copy Is hereby furnished A_/, p
f-0R APPLICANT TO FILL W(PRINT OR TYPE) ADDRESS BUILDING SY`T 1 T�
❑ Candbd copy b tiled with the county building Irepecllon .
department NUMBER FIXTURE OR ITEM O FEE LOCALITY Q �`_
Date ' Applicant / WATER CLOSET C=S ST f dW yr
CERTIFICATE OF EXEMPTION FROM WORKERS / BATH TUB _ ..
COMPENSATION INSURANCE ASSES ' a
(This nation need not be completed H the work Involved by the SHOWER MAR BOOK PAGE PARCEL
Permit Is for one hundnd flatten($100)or leu) OWNER LAVATORYOWNER WY.MAIL if" AA S
I certify that In the performance of the work for which this permit �' /' n.
Is issued I shell not employ any person In any manner n as to SINK REBS 9 4r 1� e `iI p[vo
become subject to the Workers Compensation Laws
DISWASHER CITY T' TEL NO
Data APpllaaCLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT If after making this Certificate of
Exemption,you should become subject to the Workers Compensation SWIMMING POOL RECEPTOR _
Provisions of the Labor Code you must forthwith comply with such ADDRESS '
provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION WATER HEATER - CRY ' TEL NO Q.
I hereby affirm that I em licensed under provisions of Chapter 9 STATE - 8
(commencing with Section 7000)of Division 3 of the Business and
LIC
Prof"Wone Code and my license Is in full force and effect OAS SYSTEM OUTLETS LICENSE NO CLASS
OUTLETS OVER DISTRICT NO PROCESSED By Q
5 PER SYSTEM O
Lwrolroe Number Lic Class D �` V
TE 2-24-47 VALIDATION DAT10N a
Contractor Date ♦: _ (n
E] I am exempt under Sec IN'LL ki�;CT.`* Z
B aP C la this raasan 3307 112.16
Date Plan ch19dc fee _ -
PLUMBING PERMIT ISSUING FES S _ 1 ITEMS
s�nmaro TOTAL FEE a TOTAL 112. 05
❑ - CHECK 112.05
Plan check appllcarrt
SINGLE UILDER LY uAM2 .00 "
FLORAE OWNER BUILDER DECLARATION Nemo r CTS r -
I hereby affirm that I am exempt from the Contractor a License Law
for the following reason(Section 7031 ! Business and Profession Address
Code)
❑ cloy Tel No 0000--0001 11/16/92
I as owner of the pmp" will do the work and the structure 6519 1 AM1O.52'
Is not Intended or offered for sale (Section 7044 Business `
and Professions Code) ,
� 1 _
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 3087
On, C I
LeMx s Name ,
Lendw•Address -
I certify that I have read this application and Stets that the above
Information Is correct I agree to campy with all County ordinances
and State laws regulating Plumbing, and hereby authorize — -
representatives of this County to enter upon the above mentioned
property for Insplrchorr�°urposes SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of Perfnhtee Date