HomeMy Public PortalAbout4831AGNES AVE_Plumbing (12) WORKER S COMPENSATION DECLARATION \ 200026 DPW 9/89 (CITY OF TEMPLE CITY) _
1 hereby affirm that I have a certificate of consent to self insure 76A667A APPLICATION FOR PLUMBING PERMIT
or a certificate ofyorker s Compensation Insurance or a certified
copy thereof(Sec 3800 Lab C) `
I COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
Policy No ()E)GQpmpany _
❑ Certified copy is hereby furnished® BUILDING 'FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 4831 A nes Ave C
Certified copy is filed with the county budding inspection
department NUMBER FIXTURE OR ITEM @ FEE LOCALITY
At. 4/1193 Applicant General TT1StQa $ WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE ' ASSESSOR
(This section need not be completed if the work involved by the SHOWER MAP BOOK I PAGE PARCEL
permit is for one hundred dollars($100)or less) + OWNER
I certify that m LAVATORY the performance of the work for which this permit MAIL '
is issued I shall not employ any person in any manner so as to SINK ADDRESS
become subject to the Workers Compensation Laws _
DISWASHER CITY T 5-7 7
Date Applicant + CLOTHES WASHER �
094
NOTICE TO APPLICANT If after making this Certificate of CONTRACT03 neral Tn-,taillatinn ('o-
Exemption you should become subject to the Workers Compensation { SWIMMING POOL RECEPTOR r
provisions of the Labor Code you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM
� LICENSED CONTRACTORS DECLARATION' t CITY LOS }An e 1 e S TEL NO 753-2541
+
I hereby affirm that I am licensed under provisions of Chapter 9 ` WATER HEATER a
STATE LIC
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE N01 51 8 3 9 CLASS C 3 6V
Professions Code and my license is in full force and effect
OUTLETS OVER DISTRICT NO PROCESSED BY + Ir
5 PER SYSTEM f Q
License Number 1 51 R 3 9 Lic Class 173 h
FINAL _ VALIDATION W
+ Contractor w n Prnv1 n pate 4193 DATE dr
❑ I am exempt under Sec BY AL Z
r B&P C for this reason n
Pian check fee
Date
Signature
PLUMBING PERMIT ISSUING FEE$ ±
TOTAL FEE 1
Plan check applicant 3a ++J I
SINGLE FAMILY 1 _ MT�► y
HOME OWNER BUILDER DECLARATION Name +� j �- , _ _ - AMTA -
I hereby affirm that I am exempt from the Contractors License Law - -^B r�C+".yyf,t
for the following reason (Section 7031 5 Business and Professions Address rt _ �; t } 337 w ,s9■JV
Code)
City Tel No 1 ITEC
F-1 +s ,:,.,.�...
I as owner of the property will do the work and the structurer e r TOT& :3 =s7 O
is not intended or offered for sale(Section 7044 Business - - _ _
and Professions Code) ti ( - POOL. - CECK I - 39.ai
CONSTRUCTION LENDING AGENCY ,� `` a
.00
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec 3097 -
�1= rsr- ) 7 - - " _
Civ C) 5Lt 9/ 3/922
Lender s Name _ _ - _ .++7.J'y I PH la 1$
Lenders Address
1 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 re ing Plumbing and hereby authorize t
representatives o is C unty to enter upon the above mentioned
t ) l
pr ction rposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ermlttee Date r / t