HomeMy Public PortalAbout8731 HERMOSA DR_Plumbing__ DEC
TION
WORKERS't I have
a certificate
cafe of corse APPLICATION FOR PLUMBING PERMIT {�
I hereby affirm that I have a certificate of consent to self 76A667A u
r insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) City of Temple City
or acertified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. 201916 Company SCIF
Certified copy is hereby furnished. 8973
BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 10715 Lora Street
❑X Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY Tempile, City
Date A-1—A7 Applicontreneral Tnstall WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. $$87C Santa Anita Ave.
COMPENSATION INSURANCE SHOWER OWNER Jon Hendricks
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS 10715 7 Lora Street
I 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 M82-579-4429
so as to become subject to the Workers Compensation Laws. DIS ASHERinstallation
CONTRACTOR General g t i Co
Date Applicant CLOT ASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
65SR West Blvd,
Exemption, you should become subject to the Workers' SWIMMIN LRECEPTOR
CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- Los Angeles 753-253
with comply with such provisions or this permit shall be LAWN SPRINKL TEM STATE LIC,
deemed revoked. 1 WATER HEATER 6 O LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATIONNki DISTRICT NQ.� P OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM LETS tom, /'f
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ` 1 �)
and Professions Code, and my license is in full force and effect. 5 PER SYSTEMfv VA DATION
FINAL
151839 DATE
License Number Lic. Class C36 07
F U.
Contractor W_O_ Proyin Dore 4-55"
a'
❑ I am exempt under�Sec. 0
B.BP.C. for this reason U
Plan check fee - w
poll
n
Dafe: fn
PLUMBING PERMIT ISSUING FEE S 10 0 Z
Signature
TOTAL FEE 16 Q
SINGLE FAMILY Plan check applicant ;263 6 8A
HOME OWNER-BUILDER DECLARATION Name # • • • • • 55
1 hereby affirm that I am exempt from the Contractor's License s
gddres _
Law for the following reason (Section 7031.5, Business and ) • • 65,0
Professions Code): City Tel. No.
❑ I, as owner of The property, will do the work and the , o e - 116505
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 01.2o—B-7
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construcTion lending agency for
the performance of the work for which This permit is 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
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentionedfor inspection purposes.
`� �� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of el�rm ii/ e%��jfF•�C^'�`,�' �