HomeMy Public PortalAbout5753TEMPLE CITY BLVD_Plumbing (2) WORWEV'COMPENSA?IONDECLARATION APPLICATION-FOR PLUMBING PERMIT
F f 1"h't6'e ,affirm that I Fyave a certificate of consent to self 76A887A
.4'insure, or a cedff-cote,of'Workers'Co mpensaticTn Insurance, CE 817(REV.8/86)
or a certified copy thereof(Sac, 3800, Lob: C:)
•COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
0 Certified'copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING, 7
�. Certified copy is filed with the county building Inspec- ADDRESS S 3 lY1�L.F C
tion department. NUMBER FIXTURE OR ITEM ` ® FEE LOCALITY
WATER.CLOSET - C.,
Date Applicant.. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST; .. I;[/d AQ 11C.P77 . �t/
COMPENSATION INSURANCE ' SHOWER OWNER 174 Ze Z
(This section.need not be,completed If-.the work involved by MAIL
the permit Is for one hundred dollars($100)or less.) l LAVATORY ADDRESS S/9"0011,
I. certify that in the performance of the.work for.which this
TEL.NO..'
permit is Issued,l:shall not employ any person in.any-manner SINK CITY � -�C� ,
• so as to become subject.to;the Workers,.
orkers'Compensation Laws. DISHWASHER
CONTRACTOR,
Dote 44, 7 ` Applicant CLOTHES WASHER ADDRESS ,
NOTICE TO•APPLICANT: If, after making, this Certificate of
Exemptidn, you should become .subject to. the Workers' SWIMMING POOL RECEPTOR
Com ensation rovisions of the.Labor Code, you must'forth_ CITY ' G TEL.,NO.
P P. Y LAWN-SPRINKLER SYSTEM
with comply with such •provisions or this .permit shall be STATE LIC.
- LICENSE N . CLASS. .
' deemed revoked: WATER HEATER
LICENSED CONTRACTORS DECLARATION DISTRICT NO
m P ESSE Y'
I hereby affirm that I am licensed under provtstons of Chapter 9
GAS.SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business, OUTLETS OVER
and Professions Code,and my license is in full'force and effect. 5 PER.SYSTEM` FINALVA C
Lic.:Class- „ .
• DATION
DATE
License Number -
FINAL , C
Contractor Date BY
El I am exempt under Sec:
. � d
B:AP.C.for:this reason ® �
Plan check fee - •
Dater PLUMBING''PERMIT ISSUING FEE
Signature
TOTAL FEE
A-6 8 2.0 A
Plan check applicant
SINGLE FAMILY # 0'0 0 0,o 5
HOME OWNER-BUILDER DECLARATION Name
I.hereby affirm that.)am exempufrom the Contractor's License ;i� .o 0 2950
' Law for•the following..reason.(Section'7031,5, Business-and Address
•Professions•Code): City. Tel. No. 00 -02a5050
I, as owner of t}te-property,.will do the work and the j,
structure is not intended or offensd for sale (Section o d.O 7-87
7044, Business and Professions Code). „
CONSTRUCTION LENDING AGENCY ,.
I hereby affirm that.there:Is a construction lending agencyfor ) '
the performance of the work for which.this permit is issued
(Sec: 3097,.Civ. C.):
Lender's.:Name
Lender's Address. I
I certify that I have.read this app.licati.on and state that the
above information is correct. I agree to.comply with all County
ordinances and.State.laws regulating Plumbing, and hereby
authorize representatives of fh;ts Count' to enter upon the
a ve-mentioned property for Inspection purposes.
SEE.REVERSE FOR,EXPLANATORY LANGUAGE
Signature-of Permittee _-1/ Date