HomeMy Public PortalAbout5745 PRIMROSE AVE_Plumbing__ ^/�T
D WO.RKERS'COMPEN 4TIQNDECLARa4TION Is APPL.I�rATION FOR PLUMBING PERMIT
l,'-hereby affirm that I have'ea certiflthte of cpnsent to:.self �,76A667A•% ' "'}
insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof(Sec. 3800, Lab. C..) �' COUNTY OF LOS ANGELES BUILDING AND SAFETY ,
Pollcy.No. 442586 comp.-n.
y. State Fund
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR.TYPE) ADDREs 5.745 North Primrose Ave.
Certified copy is filed with the county building.inspec-
tion department. NUMBER FIXTURE OR ITEM ® FEE
dd LOCALITY Temple _• t
Date 11/2 8 Z 8�•1ppl14ant AAA Cond. Air) WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST: Las Tunas
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed If the work involved by, AAAIL
the permit is for one hundred dollars($100)or less.) I LAVATORY ADDRESS 5745 North Primrose. Ave.
I certify that in the performance of the work for which this,
permit is issued, I shall not employ any person in any manner SINK CITY Temple CityTEL. NO.282-4652
so as to become subject to the Workers'Compensation Laws.' DISHWASHER
CONTRACTOR AAA r
Y
Date Applicant 'CLOTHES WASHER ADDRESS 101,60 g_ Vallpy 13.1.1%rd
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the'Workers,
Compensation provisions of the Labor Code, you.must.forth CITY TEL.NO.579_1800
with comply with such, provisions or this permit shall be LAWN
,STATE LIC.
deemed revoked. j WATER HEATER LICENSE.NO. 293529 CLASS C 2 Q'
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P SSED BY
I hereby affirm that I am licensed under provisions of Chapter 9, ] GAS SYSTEM OUTLETS C �/�
(commencing with Section 7000)of Division.3 of the Business OUTLETS.OVER IL
JN/ }.
and Professions Code,and my:license is in full force and effect.. 5 PER-SYSTEM FINAL
VALIDATI N O
License Number 293529 Lic Class C 2 0 DATE 4
' LFINi4�. tD
Contractor AAA Cond.. .Ai 46te 11�2 8�8 4 BYU&
1L
❑ eau
I am exempt under Sec. �
B.&P.C. for this reason ►
Plan check fee . 1 1 4 2'
-# 0 0 0 0 0
Date:
PLUMBING PERMIT ISSUING FEE$ A0 Is-b ( o c 1 650
Signature TOTAL FEE SO o a o 1 5 0 5
•
Plan check applicant ( 1.2.9`8 4
SINGLE FAMILY
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)- City Tel. No.
❑ I, as owner of the property, will do the work and-the
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 1
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 M1
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
na�rid�'rrn�mitteec
Signature of PerDate