HomeMy Public PortalAbout5122 ROSEMEAD BLVD_Plumbing__ WORKERS'COMPENSATIONDECLARATION CE71SA667A l APPLICATION FOR PLUMBING PERMIT
- I hereby affirm that I have a certificate of consent to self eiz (z-eo
insure,.or a certificate of Workers'Compensation Insurance,or
a certifi copy.thereof(Sec. 3800,Lab.C.) �-
j P �r os COUNTY OF LOS ANGELES UI WING AND SAFETY
,Policy No. Compan3
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
Certified copy.is filed with the county buildiLg inspection
NUMBER FIXTURE OR ITEM • FEE ADDRESS o cJ
departuret LOCALITY`��
WATER CLOSET
ate plicant NEAREST
61 24 CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB . — ,
COMPENSATION INSURANCE SHOWER OWNER �'tc
(This section need not be completed if the work involved JJ MAIL
LAVATORY �Y ADDRESS 41 lie—
t�
by the permit is for one hundred dollars ($100) or less.) /�
SINK CITY TEL.NOW��y�' C J 3r y CL
j GSC 7
1 certify that in the performance of the work for which this DISHWASHER / U
permit is issued, I shall not employ any person in any manner CONTRACTOR O
so as to become subject to the Workers' Compensation Laws. 3 CLOTHES WASHER O
Date Applicant ADDRESS )
SWIMMING POOL RECEPTOR ► M U
NOTICE TO APPLICANT: If, after making this Certificate of CITY n �Q, TEL. N � d
a
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM
rn
Compensation provisions of the Labor Code, you must forth- STATE r r,_ LIC. Z
with comply with such provisions or this permit shall be WATER HEATER LICENSE NO `t 1 CLASS
deemed revoked. < DISTRICT NO. PR CESSED*BY
-3 GAS SYSTEM OUTLETS �.
^ LICENSED CONTRACTORS DECLARATION OUTLETS OVER �ivr
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code, and my license is in.full force and DATE
effect. +
^ ] FINAL
License Num 4713 Lic.Classi^ l z gY y
ontractor 0 INA Datel3e�'
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). p—�
TOTAL FEE J
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):
I, as owner of the property, am exclusively contracting z 2 6 1.7 p,
with licensed contractors to construct the project
(Section 7044,Business and Professions Code). # o o o o o 5
CONSTRUCTION LENDING AGENCY
2 - 1 7'650
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is o 0 1 7.6 5 0 U
issued(Sec.3097,Civ.C.). 0 1. 1382
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned pr perty for ins on purposes.
f
Signature of Permittee Date
WORKERS'COMPENSATION DECLARATION 76A667A
I hereby affirm that I have a certificate of consent to self ce 617 (2-e0) APPLICATION FOR PLUMBING PERMIT
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy 4'Jf ,f��.there e . 3800,Lab.C.)
/ COUNTY OF LOS ANGELE �� . BUILDING AND SAFETY
Policy NoUN Y Company ��L f�,�`� �
Certified copy is hereby furnish FOR FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
NUMBER FIXTURE OR ITEM • FEE ADDRESS = AC),jt'Sr`YI Qr7yD
Certified copy.is filed with the county building inspection ,
LOCALITY C"
�tepartment. WATER CLOSET ZV�,e Applicant NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER �V
LAVATORY MAIL l
(This section need not be completed if the work involved ADDRESS ��. r�( , /u-`/�L'6+/7JL' �eIV
by the permit is for one hundred dollars ($100) or less.) SINKCL
CITY TEL. NO. O
1 certify that in the performance of the work for which this DISHWASHERd C t/� U
permit is issued, 1 shall not employ any person in any manner CONTRACTOR J<7rJ/'f°� oz; 5 lY
so as to become subject to the Workers' Compensation Laws. CLOTHES WASH ER
ADDRESS
Date Applicant SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO3 a
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC.
Compensation provisions of the Labor Code, you must forth- LICENSE NO. ` (,6) d CL
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked. GAS SYSTEM OUTLETS DIST'/RII T NO. P CESSED BY
/f
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL VALIDAT N
ness and Professions Code, and my license is in full force and DATE (, �,
effect. ,t✓ J s"
lC3C�E>C9.L FINAL
License Number Lic.Class BY
s
Contractor S0,92U4/7 Date
C•.`�' NCaL` Plan check fee
ElI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
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 2 2 7 6 9 A
License Law for the following reason (Section 7031.5, Busi- City Tel.No. # 0 0 0 0 0 5
ness and Professions Code):
0 I, as owner of the property, am exclusively contracting 2 0 0 1 6,50
with licensed contractors to construct the project
(Section 7044, Business and Professions Code). 0 0 0 1 6,5 0 H
CONSTRUCTION LENDING AGENCY 0 1.27-82
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentiiod property for inspection purposes.
+!/ 7 4�Z
Signature of Permittee Date