HomeMy Public PortalAbout4916 ROSEMEAD BLVD_Plumbing__ 0 WORKER'S COMPENSATION DECLARATION 20.0026 DPW 9/89
1 hereby affirm that I h2,e a certificate ofconsent to self insure, 76A667A APPLICATION FOR PLUMBING PERMIT
or a certificattptif Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No. Company
❑ Certified copy is hereby furnished.
E-1FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
ADDRE S
Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. -
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if,the work involved by the
SHOWER 50
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) OWNER
I certify that in the performance of the work for which this permitMAIL
LAVATORY
is issued, I shall not employ any person in any manner so as to SINK ADDRESS
become subject to the Workers'Compensation Laws.
DISWASHER CITY TEL.NO.
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR AI b
Exemption,you should become subject to the Workers' Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO. }
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
(commencing with Section 7000) of Division 3 of the Business and STATE LIC.LICENSE NO. CLASS 0
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS U
OUTLETS OVER DISTRI6 ROCESSED it
5 PER SYSTEM (x/)
License Number Lic.Class
FINAL
DATE 5 /IVL IDATION LU
Contractor Date (n
❑ FINAL1/3
I am exempt under Sec. BY
B.&P.C.for this reason
Date: Plan check fee ,
Signature PLUMBING PERMIT ISSUING FEE$ LO
F-1 TOTAL FEE 1 _
Plan check applicant
SINGLE FAMILY A(_;t;1=a
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law ]330
for the following reason(Section 7031.5, Business and Professions Address
Code):
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El 1,
Tel.No.
1, as owner of the property,will do the work and the structure 1-113T L 35 5
is not intended or offered for sale (Section 7044, Business
and Professions Code). , ;•'t'ECiv. —5
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CONSTRUCTION LENDING AGENCY t_HAN-G,E
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!l'i —i
. 000 1 8i 6.P4_0
Lender's Name '2428, i qrl 8 15
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
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