HomeMy Public PortalAbout5709-5711TEMPLE CITY BLVD_Plumbing (2) DEC
TION
WORKERS't I hay a certificate
cafe of corse APPLICATION FOR PLUMBING PERMIT
'thereby oHum that I hove o certificate of consent to self 76A6yq
insu7e ora certificate of Workers'Compensation Insurance, CE 817(REV 10/81)
or a certified copy thereof (Sec 3800 Lob C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Irn Certified copy is hereby furnished FOR AFRICAN TO FILL IN(PRIM OR TYPE) BUILDING /
til Certified copy is filed with the aunty building spec- ADDRESS
hon depo ent NUMBER FIXTURE OR ITEM ® FEE
LOCALITYDate APpliSan WATER CLOSET NEAREST ,
IFICATE OF EXEMPTIO FROM WORKERS BATH TUB CROSS ST a
COMPENSATION INSURANCE OWNER
(This rection need not be completed if the work Involved by SHOVER Q
the permit is for one hundred dollars($100)or fen) LAVATORY ADDRESS o�d r� Gam`
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY L NO
so as to become subject to the Workers'Compensation Laws DISHWASHERz
CONRACTO
Date Applicant CLOTHES WASHER,
NOTICE TO APPLICANT If after making this Certificate of ADDRESS f' p,
Exemption you should became subject to the Workers
SWIMMING FOOL RECEPTOR
Compensation provisions of the Labor Code, you must forth LAWN SPRINKLER SYSTEM CfiY TELOXj
with comply with such provisions or this permit shall be TTXTE
7� LIC E� C „
deemed revoked WATER HEATER LICENSE NOcAss
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
1 hereby affirm that 1 am licensed under provisions of Chapter 9 GASSYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER t y
and Professions Cade,and my license is in full force and effect 5 PER SYSTEM FINAL 6
.s�O �e y��. a� DATE _ VAII TION U
License Number J— 76 Ltc ClassS.0 —8 _� ad
�.'�b FI O
Contract O 6te Y/f. ! 6 B&
JIL4f U
T�
❑ I am exempt under Sec 1N
B 8P C for this reason Z
Plan check fee
Date PLUMBING PERMIT ISSUING FEE$ ;@1 4 a 3 A
Signature
TOTAL FEE r e e 5
Plan check applicant ( • • (�5 0
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Name • e e ' 5 0
I hereby affirm that 1 am exempt from the Contractor's License Address
Law for the following reason (Section 7031 5, Business and 0 Z 0 5—a 5
Professions Code) City Tel No
❑ 1 as owner of the property, will do the work and the
structure Is not intended or offered for sale (Section ,
7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby off rmi that there so construction lending agency for
the performance of the work for which this permit is issued
(Sec 3097 Civ C )
Lender s Nome
Lender s Address
I certify that I hay r a his application and state that the
m ►
above mforot, s r t I agree to comply with all County
ordinances and t I regulating Plumbing, and hereby
authorize repr of this County to enter upon the
a e-menti f ion purp s
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee