HomeMy Public PortalAbout5728 A-ETEMPLE CITY BLVD_Plumbing (2) '• WORKER 8COMPENSATIONDECLARATION 2Pd0411DPW 918a APPLICATION FOR PLUMBING PERMIT
I he}eby affirm that I heves cerllllcele of consent to self Insure 711AWA
or a certificate of Worker f CYritpensawn Insurance or a certified - - -
copy therbof(Sec 31100 Lab C) U
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
Patcy No Comby l
❑ Derailed copy Is hereby furnished - J C
❑ CerWW copy Is Ned with the coumy building empecuoi FOR APPLICANT TO FILL IN(PRINT OR TYPE) . ADDRBUILDESS i,C� P� )
ADDRESS J
department NUMBER FDOURE DR ITEM 9 FEE LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS �ST
BATH TUB
COMPENSATgNINSURANCE ASSESSOR
(This taction need not be completed If the work involved by the SHOWER MAP BOOK PAGE PARCEL
permit It lar one hundred dollars($100)w Is"I LAVATORY OWNER i/A/1 n
I certify that in the performance of the work for which this permit MAIL �,t
Is Issued I shall not employ any person In any manner so as to SINK
become subject to the Workers Compensation Laws ADDRESS ` hf .S'O. .yes zQtL,-
p DISWASHER CITY TEL ../
Data /^�-�/t7 Applicam�Y/LT/rC0 1r l� CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT If after making this Certificate of
Exemption you should become subject to the Workers Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code you must forthwith comply with such I ADDRESS
provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM2 no
LICENSED CONTRACTORS DECLARATION WATER HFJITFA CITY T V TEL NO a
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business and STATE UC 0
ppA SYSTEM OUTLETS LICENSE NO CLASS 0
Professions Code sand my license is In full Twos and effect
OUTLETS OVER DISTRICT NO PROCESSED BY Q
a PER SYSTEM Q
License Number Lrc Clem V
Connectorn Data
FINAL VALIDATION UU
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❑ I am exempt under Sec FINAL Z
BY
B SP C for this reason
cafe Plan check fee _ ,
Signature
PLUMBING PERMIT ISSUING FEE$
❑ TOTALFEE Q
Plan check applicant c
SINGLE FAMILY
HOMAt C T�t
E OWNER BUILDER DECLARATION Name
I hereby affirm that I on exempt from the Contractor a License mins Law _ T
for the following reason (Section 7031 6 Business and Pwbesmns Address - GJt)7 20.!I)
Code)
❑ m owner of the City Tel No 1 ITEM='
I
property will do VIS work 70 the structure
Is "I Intended or offered for Bele (Section 7011 Business TOTAL., 20 w 50
and Professions Code) - -, SCK, 20.50
CONSTRUCTION LENDING AGENCY t H17� 1 rU
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) _ � f 0001' 11 11/ �4ti l
Lander a Name 3641 1 AM10:24
Leader a Address `
I certify that I have read this application and state that the above Poo.Information b 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 above mentioned `
property for inspection purposes t SEE REVERSE FOR EXPLANATORY LANGUAGE