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HomeMy Public PortalAbout5454TEMPLE CITY BLVD_Plumbing I �• A-- 1MOCOMPENSATION DE um th CLARATION APPLICATION FOR PLUMBING PERMIT I hereby offthorn certificate acertcertificatea -0 icaof consent self 40048 DPW 8/87 j insure or a certificate of Workers Compensation Insurance 76A667A qr a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS II Policy No Company r Certified copy is hereby furnished ❑ FOR APPLICANT TO FILL IN(PRIM OR TYPE) BUILDING Certified copy is filed with the county budding Inspec ADDRESS 49 hon departmant NUMBER FIXTURE OR ITEM ® FEE LOCALITY Date Appigant WATER CLOSET NEAREST I r CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS COMPENSATION INSURANCE OWNER (This section need not be completed If the work Involved by SHOWER - - the perinit Is for one hundred dollars ($100)or less ) LAVATORY MAIL r ADDRE I certify that In the performance of the work for which this permit Is Issued, I shall not employ any person in any manner SINK CITY TEL NO 01 so as to become Subject to the Workers'Compensate awe DISHWASHER CONTRACTOR Data04K/WiAppllcantj�w CLOTHES WASHER , ADDRESS NOTICE 1b APKICANT If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth LAWN SPRINKLER SYSTEM CITY TEL NO with comply with such provisions or this permit shall be STATE LIC deemed revoked WATER HEATER LICENSE NO CLASS LICENSED CONTRACTORS DECLARATION LyS'RICT NO v I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 5 (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER s and Professions Code and my license is in full force and effect 5 PER SYSTEM FINALDATE � ALIDATION O License Number Lec Close U FINAL BY Contractor Date 0 ❑ 1 am exempt under Sec (� B BP C for this reason Plan check fee Date PLUMBING PERMIT ISSUING FEE{ Z Signature TOTAL FEE Pian check applicant SINGLE FAMILY 5 HOME OWNER BUILDER DECLARATION Nome R I hereby affirm that I am exempt from the Contractor s License Address - AUT'C i Low for the following reason (Section 70.31 5, Business and 3W ,�. Professions Code) City Tel No 50 I, as owner of the property, will do the work and the ` 1 ITEMS structure is not intended or offered for sale (Section TOTAL 22.50 70" Business and Professions Code) Poo CONSTRUCTION LENDING AGENCY (SCK 71.50 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued _ C .OD (Sec 3097 Civ C ) Lender's Name 0000-Ml 8/25/89 Lender s Address 5315 1 AM10:59 1 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 reprelentatives of this County to enter upon the , above mentioned propppeeeryryryyyy for nswchon purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 'Signature of Permittee Dbte