HomeMy Public PortalAbout5450TEMPLE CITY BLVD_Plumbing (2) WORKERS COMPENSATION DECLARATION ` -APPLICATION FOR PLUMBING PERMIT
I hereby, affirm v
m that I have a tertificpte of consent to self in- ZO-ODPW 90
sue or a ceNdlcote of Worker'Compensation Insurance,ora 76A667A v
certified copy,thereof(5x Lab C )
Company
- COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS t
Policy No ...,10555 company REPIJgTC TNDQ�NIlY
E] Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRIM OR TYPE) BUILDING
Certified copy a filed with the county budding inspection FOR
department a�Ly-I NUMBER FIXTURE OR ITEM ® FEE LOC LTY MTIE CITY, CA `
Date_Q�A 0!J4 Applica t / // WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' ' BATH TUB CROSS ST
COMPENSATION INSURANCE _ SHOWER OWNER BLPNION OaVn?L •ICN
(This section need not be completed If the war*Involved by
the permif b for one hundred dollar($100)or Mss) LAVATORY 0 D ADDRESS 152 W. PCl CNA AVE. '
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so O CITY , CA91016 TEL M/574-0$38
as to become subject to the Workers'Compensation Lawn
DISHWASHER O CONTRACTOR FRANC MAR%2E & SCt1S, INC.
Dote Applicant CLOTHES WASHER /B 9860 ADDRESS
LOWERSDIA
SA D
NOTICE TO APPLICANT If, after making this Cernftcote of Ex- SWIMMING POOL RECEPTOR
emption,you should become sub ect to the Workers Compen- crrYEL M]NLE, CA 91731 TEL NI$1$/444-2548
sahon provisions of the Labor Core,you must forthwith comp- LAWN SPRINKLER SYSTEMS
Ilywith such provisions or this permit shall be deemed revok /� STATE LIC
WATER HEATER LC (D LICENSE No 397884 &SS C/36 C/16
LICENSED CONTRACTORS DECLARATION v DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter OAS SYSTEM OUTLETS ( `Of
9(commencing with Section 7000)of Division 3 of the Business 55 PER SSSS�R _ v JF
and Professions Code, and my license is in full force and of
fest HOSE BIB FINAL VALIDATION
License Number 397884 Lic Class C/M C/16 _ G
FINAL V
ContractorF• 14ARRONE & SCNS. Iljjota 12/31/96 _ BY g
I am exempt under Sec 4(,r., H
B&P C for this reason ► 6.i W
Plan check fee Datey�� �33j
e PLUMBING PERMIT ISSUING FEE S
SignatureAVM- TOTAL FEE
091 9�_SINGLE FAMILY Pan check applicant
HOME OWNER-BUILDER DECLARATION PP
I hereby affirm that I am exempt from the Contractor s License Name
Law for the following reason (Section 7031 S Business and
Professions Code) Address
❑ I as owner of the property, will do the work and the City Tel No
structure is not intended or offered for sale(Section 7044
Business and Professions Code)
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 )
1
Lender's Name
Lender s Address '
I certify that I have read this application and state that the i ,
above ma formotion 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
a ve-menu red property for inspection purposes
�f—,'-&~9s SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of litermittee Date