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r -WORKERS'COMPENSATION DECLARATION 76A60'I
I hereby a4irm that I have a certificate of consent to self CE fiv (z-aa) APPLICATION FOR PLUMBING PERMIT
ins-Ere,..or a certificate of Workers'Compensation Insurance,or
a certified copy.thereof(Sec. 3800,Lab.C.)
377?�( COUNTY OF LOS ANGELES �' BUILDING AND SAFETY
Policy No. Company State Compo ins o F'Ul d
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
O Certified copy.is filed with the county building inspection
NUMBER FIXTURE OR ITEM • FEE ADDRESS
d partme t. 1 WATER CLOSET LOCALITY Temple City
Date �— l— � Applicant NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER (11+ii7 of Temple e r_J r
LAVATORY MAIL `
(This section need not be completed if the work involved 1 ADDRESS 5938 Tho ��aUifma2l Avenue >
by the permit is for one hundred dollars ($100) or less.) SINK a
CITY Temple City TEL. NO. 28j_2171
I certify that in the performance of the work for which this DISHWASHER CONTRACTOR
permit is issued,I shall not employ any person in any manner Tn _ ,rr c T_3_ ,, ;,, C i cc
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER 0
ADDRESS 9125 E. Las Tulzas Drive
Date Applicant SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tem le Cit TEL. NO- 285-3224 Lou_
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM N
P J STATE LIC.
Compensation provisions of the Labor Code, you must forth- LICENSE NO. 279687 CLASS C-36
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PROQJESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL
c`6
ness and Professions Code, and my license is in full force and SeWe Ejector DATE VALIDATION
effect.
FINAL ,mm.� Mr
License Number Lic.Class BY �
Contractor Date
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ '
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE f
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's
Address
License Law for the following reason (Section.7031.5, Busi- City Tel.No.
ness and Professions Code):
OI, as owner of the property, am exclusively contracting
with licensed contractors to construct the project 0 2 3,2 A
(Section 7044, Business and Professions Code).
# o'aoo88
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 0 0 0 0 0 0 0
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). 0 7 0 7°8 1
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is c ect.I agree.to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinan s and Sta 1 ws reg Plumbing, and hereby
auihori a epresen tiv o his ounty to enter upon the
above- a ti ed top ty or' pection purposes.
Sig ture of Permittee Dat