HomeMy Public PortalAbout5722 A-ETEMPLE CITY BLVD_Plumbing ^WORKER S COMPENSATION ATIQN 9189APPLICATION FOR PLUMBING PERMIT
' I herebffi
y arm that I Jove a certificate
consent of consent to self insure
or a certificate oRWarkpr a Compensation Insurance or a certified
copy thereof(Sec 3&00 Lab C) I -
Pohcy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
❑ ' CemAed cagy is hereby furnished —
❑ _FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING e� r�
certified ti
hed copy led with the county bulking Impaction ADDRESS O�- L
department NUMBER FIXTURE OR ITEM a FEE LOCALITY
Data Applxxurt WATER CLOSET L
NEAREST
CEil nFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
- COMPENSATION INSURANCE ASSESSOR =
(This section need not be completed If the wort Involved by the SHOWER MAP BOO( PAGE PARCEL
permit is for one huntlntl dollen(1100)or Nes) LAVATORY OWN cw .!a rd f r
I certify that In the performance of the work for,which this permit r G�
Is issued I shall not employ any person In any manner so as to MNL
SINK MAILADD3
became subject to the Workers Compensation Lewe
o �� �y DISWASHER
CITY TEL HO
Date l��� _LQ Applicant "t 7;7" */14 CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT If aftesr along 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 CITY TEL NO }
I hereby affirm that I am licensed under provisions of Chapter B WATER HEATER (ab�
(commencing with Section 7000)of Division 3 of the Business and STATE LIC
Professions Code and my license is in full force and effect GAS SYSTEM OUTLETS LICENSE NO CLASS
OUTLETS OVER DISTRICT Y
O P OESSED S
5 PER SYSTEM O
License,Number Lio Cress
DAATE/- 3/-9i VALIDATION Wa
Contractor Date11
p
❑ 1 am exempt under Sec gyNA� 7 Z
B&P C for Oss reason (/
Date Plan check fee
Signature PLUMBING PERMIT ISSUING FEE i
❑ TOTAL FEE
SINGLE FAMILY Plan Check applicant c 1 ITEMS
EMO
HOME OWNER BUILDER DECLARATION Namp fa.SL t 20 _ CQ
I hereby affirm that I am exempt from the Contractor s License Law _ _ 1N
for the following reason(Section 7031 5 Business and Professions Address Y �
Code) r
I aa owner of the r Cay _ Tel No
❑ prop" will do the work end the structure 4T0vnJC .1�1 '
r
is not intended or offered for sale (Section 7044 Business
and Professions Code)
CONSTRUCTION LENDING AGENCY _ 3000-0001 11/ 290
I hereby affirm that there is a construction lending agency for the r ' 36+0 1 �11C1o�',
performance of the work for which this permit is issued(Sec 3037 -
CIV C)
Lender a Name ,
Lender a Address --
I certify that I have reed this application and elate that the above- -
information is correct I agree to comply with MI County ordinances
and State laws regulating Plumbing and hereby authorize -
representativee of this County to enter upon the above mentioned -
property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE