HomeMy Public PortalAbout5722 A-ETEMPLE CITY BLVD_Plumbing (2) -Y • WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I-have a cerehcote of consent to self m- 76A667 DPW a/87
A
sure, or d certif¢ote of We4CE 81 7kers Compensation InwroncA,or CE 817(REV 8/66) �
certified copy thereof (Set 3800, Lx* C )
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
'Policy Plo Company r
Certified copy is hereby furnished
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN (PRINT OR TYPE) r BADDRE55
WG
department NUMBER FIXTURE OR ITEM' ® FEE LOCALITY ? ie
Data Applicant WATER CLOSET(TOILET) NEAREST G
CERTIFICATE OF EXEMPTION FROM WORKERS
BATH TUB CROSS ST (�
COMPENSATION INSURANCE OWNER
SHOWER
(This section need not be mmplofid If the work Imolred by MAIL rz _
the Permit Is for one hundred dollars($100)or less) LAVATORY ADDRESS 1-7
1 certify that in the performance of the work for which this per 30
mit is issued I shall not employ any person in any manner so Q SINK CITY f v TEL rJ0
as to become subject to the Workers'Compensation Laws DISHWASHER v
CONTRACTOR
Dote Applcont CLOTHES WASHER
NOTICE TO APPLICANT If after making this of Ex
emotion you should become subject to theo Workorkersrs Co SWIMMING POOL RECEPTOR ADDRESS
mpen CITY TEL NO /
sohon provisions of the Labor Code you must Forthwith comp LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE //` L(C
ed - x WATER HEATER LICENSE NO CLASS 16
LICENSED CONTRACTORS DECLARATION D15TRICT-1.0 SSED B
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS `L=J� O
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER r
and Professions Code and my license is in full force and of 5 PER SYSTEM FINAL/��//�6� VA IDATI N d
fact DAT
License Number Lm Claes O
FINA cc
Contractor Date BY - Q
O
F
I am exempt under Sec i W
B Plan check fee 8P C for this reason , - q
Z
Date PERMIT ISSUING FEE S b
Signature - TOTAL FEE f
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION5
I hereby affirm that I am exempt from the Contractor s License Nome
Low for the following reason (Section 7031 5;Business and �T.y
Professions Cade) Address T
F] I as owner of the property, will do the work and the City Tel No M7 63.Dp
structure is not intended or offered for sole(Section 7044 1 LTEM
Business and Professions Code) _ - , TOTAL 63 w QD
• CONSTRUCTION LENDING AGENCY CHECK I hereby affirm that there is a construction lending agency for z 63.00
the performance of the work for which this permit is issued �s�Asy�
(Sec 3097 Civ C ) �r�Ry��,rCt�t .00
Lender a Name uwu—UW 1 1/16/90
Lender s Address ' 882&4 1 AM11o30
I certify that I have read this application and state that the '
above information is correct I agree to comply with all County ►
s ordinances and State laws regulating Plumbing, and hereby /
authorize repro entati s of this County t enter upon the
above- arty for inspectio urpo
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ature of Permit ee to '