HomeMy Public PortalAbout5810TEMPLE CITY BLVD_Plumbing (2) a• E.mrORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
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R hereby,affirm that I have'a c6tificate of consent to self 7BA887A Vlul
insure, or a certificate of Workers'Compensation Insurance, CE 817(REV.8/88)
or a certified copy thereof(Sec. 3800 Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No.'C?Qopl-Z"ompany
❑ Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS � �`e �I
Certified copy is filed with the county building Inspec- NUMBER FIXTURE OR ITEM ® FEE
tion department. LOCALITY
Date?-r::IF
�L Appli4anf 400:ZWATER WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST.
COMPENSATION INSURANCE OWNER
(This soction need not be comploted if the work Involved by SHOWER �/ p /�
tho permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS / /C7KVG v 42
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL.N 772
so as to become subject to the Workers'Compensation Laws. DISHWASHER /
CONTRACTOR CK2�e
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS 0 e-
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL.N0
96�
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. 2 WATER HEATER LICENSE NO. (i CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. )PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 ! GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER I
and Professions Code,and m license is in full force and effect. 5 PER SYSTEM a
�f LY DATE L VALIDATI v
License Number v "6 Lic.Class_ U
�� L9`�@>� FINAL
Contractor _ate BY O
❑ I am exempt under Sec.
a �
B.BP.C. for this reason
Plan check fee Z
Signature
Date: PLUMBING PERMIT ISSUING FEE$ ,
v
TOTAL FEE IiJ ��
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for-the following reason (Section 7031.5, Business and
Professions Code): I City Tel. No.
❑ 1, as owner of the property,will do the work and the
structure is not intended or offered for sale (Section ; 9 7 3 a 9 A
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY I # 4 6 5 0
0'0
I hereby affirm that there is a construction lending agency for j
the performance of the work for which this permit is issued o 0 - 46505
(Sec. 3097, Civ. C.).
I 07,01 687
Lender's Name
Lender's Address
I certify that I have read this application 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 this County to enter upon the ;
above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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Si nature of Permittee Date