HomeMy Public PortalAbout5124 ROSEMEAD BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION 76a667w
I hereby affirm that I have a certificate of consent to self cEa17 (z-ao) APPLICATION FOR PLUMBING PERMIT.
insure, or a certificate of Workers'Compensation Insurance,or �—f--
a certifigd copy there f(Sec.3800,Lab.C.) / 7
�g,�oa�PI C ��� ( COUNTY OF LOS ANGELES BUI WING AND SAFETY
Polk Ifo. Compan [_t rl.fatioL
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS (J -44 ad-
Certified copy is filed witp4e county build' inspection NUMBER FIXTURE OR ITEM • FEE
LOCALIT
de artmen C N WATER CLOSET 'o� J NEAREST C
Date I i c a n t
6 BATH TUB CROSS ST. �..c—
CERTIFICATE OF EXEMPTION FROM WORKERS' 1
COMPENSATION INSURANCE SHOWER OWNER t LJ 3
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(This section need not be completed if the work involved LAVATORY , � IADDRESS�SJ Ei
by the permit is for one hundred dollars ($100) or less.) SINKS
CITY TEL.NO
I certify that in the performance of the work for which this DISHWASHER /
permit is issued, I shall not employ any person in any manner CONTRALTO t) O
so as to become subject to the Workers' Compensation Laws. 3 CLOTHES WASHER / U
ADDRESS3� G -L LLI
Date Applicant o-
SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO. r'" 3 N
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. /
Compensation provisions of the Labor Code, you must forth- % LICENSE NO CLASS �+
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked. r GAS SYSTEM OUTLETS DISTRICT NO. PROC SED BY-
LICENSED CONTRACTORS DECLARATION OUTLETS OVERi�0;
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL i�
VALIDATION
ness and Professions Code, and my license is in full force and L DATE �: t •y•t�-�^
effect.
FINAL
License NumVel r� Lic.Class ✓ BY Z
`
Contracto f- )O N) R& Date /",l3
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ Q /�
acting in my professional capacity (Section 7051, Bus-
mess 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
License Law for the following reason (Section.7031.5, Busi- City Tel.No.
ness and Professions Code):
ElI, as owner of the property, am exclusively contracting 2 ° 1 7-650
with licensed contractors to construct the project ° ° 1 71650 c=i
(Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY Q 1, 1 3-82
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-mentioned property for insp c ' n purposes.
Signature of Permittee Date