HomeMy Public PortalAbout5442TEMPLE CITY BLVD_Plumbing (2) WORKERS'COMPENSATION DECLARATION ,�,DPW 4/90 APPLICATION FOR PLUMBING -PERMIT
reby, affum that I have a certificate of consent ro self in- 76A667A
or a certdicote of Workers'Compenwtmn Inaumnce,ar a - _
ed copy thereof(Sec 3800 Lab C ) -
`o icy No Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS T
Certified copy Is hereby furnished
Certified co a filed with the coup building FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ,u i
PY county ng impechon ADDRESS �s l Y�
department NUMBER FIXTURE OR ITEM 6 FEE
LOCALITY
Date Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' w'
BATH TUB CROSS ST A
COMPENSATION INSURANCE SHOWER OWNER CIA
(This stolon need not be completed H the work Involved by MAR
the permit Is for one hundred dollen(1100)or bis) LAVATORY O A.DDRE55 L.y
I certify that in the performance of the work for which this per- SINK A& D C'� TEL
ma is issued I shall not employ any person in any manner so
as to become subject to the Workers'Compensation
DISHWASHER CONTRACTOR
Date c -�q- Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
C,
emptron, you should become subject to the Workers Compen-
sahon provisions of the Labor Corte,you must forthwith comp- TEL NO
LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok STATE LLC
ed WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I herebyaffirm that I am licensed under Gas SYSTEM OUTLETS !O y
sion3 oft a Chapter d' O
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full farce and ef- 5 PER SYSTEM FINAL VALIDATION
fest HOSE BIB DATE
License Number Lic Class O
FINAL
Contractor Date _ BY W
F1O
am exempt under$ec 5 1.-
B
B 8P C for this reason ACCT.: W
Plan check fee ,
Date PLUMBING PERMIT ISSUING FEES 7,50
403 59.50
Signature - 1 ITM
SINGLE FAMILY TOTAL FEE D TOTAL 59 . 5113
HOME OWNER-BUILDER DECLARATION Plan check applicant-
1 hereby affirm that I am exempt from the Contractor s License [AddressC/;'5FZ/.
me CWCK 59.50
Law for the following reason (Section 7031 5, Business and C .00Professions Code) - kt QA1, os owner of the property will do the work and the yC Tel No /
polf
structure is not intended or offered for sale(Section 7041 �Q—[�Ol y`29/96
Business and Professions Code)
CONSTRUCTION LENDING AGENCY ► 5091 1 Ph 6:19
1 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 a Name
r
Lender s Address _
I certify that I have read this application and state that the ,
above information 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
abov -menti d pr arty spection purposes
K ..& � C a - SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Perm Mae Date