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WORKERS COMPENSATION DECLARATION 78A887A APPLICATION FOR PLUMBING PERMIT
i hereby affirm that I have a certificate of consent to self ce e17 (z so)
insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C)
372256 State CompInsFund COUNTY OF LOS ANGELES S BUILDING AND SAFETY
o . .
Policy NCompany
Certified copy is hereby furnished ;7-1 7-d-:;� FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS 531 Alessandro
®
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE
" rl ar a WATER CLOSET LOCALITY Tem
Datel � �l Applicant John Ricci NEAREST
e BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE SHOWER OWNER Robert Bryce
MAI L
(This section need not be completed if the work involved LAVATORY ADDRESS 5315 Alessandxo
by the permit is for one hundred dollars ($100) or less) SINK
CITYTemple City TEL N028 2861 U
I certify that in the performance of the work for which this DISHWASHER
permit is issued I shall not employ any person in any manner CONTRACTOR Johan 's Plumbing Service Q
so as to become subject to the Workers Compensation Laws CLOTHES WASHERI—
Date Applicant ADDRESS 9125 E. Las Tunas Drive a
SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT If after making this Certificate of CITY Temple i TEL NO N
Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE LIC ,�1��� z
Compensation provisions of the Labor Code you must forth LICENSE NO 279687 CL-ASS 6 SC44
with comply with such provisions or this permit shall be 2 WATER HEATER -Solar
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO RO SED BY }
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Bust FINAL "7 VALIDATION
ness and Professions Code and my license is in full force and DATE J r
effect
279687 C-36 SC-44 FINAL o►-
License Number Lic Class BY
Contractor John Ricci Date 12-23 n81
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051 Bus
iness and Professions Code) TOTAL FEE
•. i
Lie or Reg No Date Plan check applicant
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractors Address
License Law for the following reason (Section 7031 5 Bust City Tel No zQ 2 4 U,2 A
ness and Professions Code)
I as owner of the property am exclusively contracting y # oto 0 0 0 5
with licensed contractors to construct the project
(Section 7044 Business and Professions Code) 2,o 0 1 Q Q
CONSTRUCTION LENDING AGENCY 0 0 0 1 6 Q=
c�
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 1 2 2 3—8 1
issued(Sec 3097 Civ C)
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above me)toned property for inspection purposes
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gnature of Permittee D e
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