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Home My Public Portal About4912 ROSEMEAD BLVD_Plumbing__ WORKERS' COMPENSATION DECLARATION 26 APPLICATION FOR PLUMBING PERMIT I hereby,affirm that I have a certificate of consent{o self in-' '76A667A PW 4/87 r sure,o�a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) �IUI certified'copy thereof (Sec. 3800; Lab C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS "Policy No. Company Certified copy is hereby furnished: FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING _ Certified copy is filed with the county building inspection ADDRESS 1 ,C>?,� department.. NFEE UMBER FIXTURE OR ITEM LOCALITY , . @ WATER CLOSET,(TOILET) Date Applicant NEAREST p CERTIFICATE OF EXEMPTION FROM',WORKERS' BATHTUB /1 CROSS ST. COMPENSATION INSURANCE � OWNER SHOWER a &D A)AP,J Ctrl A'NCa (This section need•not be completed if the work involved by MAIL the permit*s foi'one hundred.dollars ($100):or.less.) I LAVATORY 9 P_ - _n . _ ."r � ADDRESS �� 1 - )J:`K.©Q� i ��. • I certify that•in'the performance of the Work fog which this per- "?!". SINK mit is issued;-1.shall not employ any person inany manner so - CITY TEL, NO. �� Ci-� as to become.subject to the Workers'Compens6tion,Laws. DISHWASHER CONTRACTOR w p��t Date - •'- Applicant " . - 'CLOTHES WASHER V NOTICE TO APPLICANT: If, atter making this Certificate of Ex- ADDRESS em tion, you should become subject to the�Workers'Com en- SWIMMING POOL RECEPTOR P I p CITY TEL. NO. ' sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok` STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT No. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL - VALIDATION fect. DATE O License Number Lic: Class 0 FINAL 19 Contractor Date BY O l am exempt under Sec. LU B.BP.C: for this reason Plan Check fee Date: PLUMBING PERMIT ISSUING FEE $ Signature TOTAL FEE46B7) :," - SINGLE FAMILY _ HOME OWNER-BUILDER DECLARATION Plan check applic'ont _.. _t I hereby affirm That 1 am exempt from the Contractor's License Name ................. a Low for the following-reason (Section.7031.5, Business and ACCT.e Professions Code): Address 330740 c� .t.. Ell'I,'as owner of the property, will do the work and the City Tel. No. - `' ...•f -1 ITEMS structure is n'ot intended or offered for sale(Section.7044, Business and Professions Code). _TTAL '.0 .50 r CONSTRUCTION LENDING AGENCY_ OECK 40.`�I 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. i / / . Lender's Name i�V66WiiJ" i �/,tt9: l v? Lender's Address * X771 1':. "1111 7:022 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 authoriser resenta�ives of this County to enter upon the abov e ioned o spection purpose o SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Perini"tge Date "