HomeMy Public PortalAbout5126 ROSEMEAD BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION 76A667A
I hereby .affirm that I have a certificate of consent to self CE 617 (2-66) APPLICATION FOR PLUMBING PERMIT
insure,.or a certificate of Workers'Compensation Insurance,or
a rc�tified copy.thereof(Sec. 3800,Lab.C.)
-�� . S � � COUNTY OF LOS ANGELES WILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS
Certified copy.is filed with the county buildin inspection NUMBER FIXTURE OR ITEM • FEE
lepartme /r�� WATER CLOSET LOCALITY
Date Applicant WINS U I NEAREST
BATH TUB l� CROSS ST. �F
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER i OWNER
MAIL
(This section need not be completed if the work involved 1 LAVATORY 3 ADDRESS ' de }
by the permit is for one hundred dollars ($100) or less.) SINK j CITY TEL. N OL3ff CL
I certify that in the performance of the work for which this `� DISHWASHER " V
permit is issued, I shall not employ any person in any manner 3 � CONTRACTOR � �� ��5 � 0:
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER 0
ADDRESS
Date Applicant SWIMMING POOL RECEPTOR G U
NOTICE TO APPLICANT: If, after making this Certificate of CIT TEL. NO '/��� a
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. Cn
Compensation provisions of the Labor Code, you must forth- LICENSE N CLASS _
with comply with such provisions or this permit shall be WATER HEATER ..
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. P OCESSED B
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL a�
'ness and Professions Code, and my license is in full force and DATE
�� VALIDATION
effect. 1
•t? 9 2 �? j_ FINAL
License Numb L"-� Lic. Class.A —J(� BY
Contract oft Date i13^�.f�►
DI am exempt from the licensing requirements as I am a Plan check fee 19
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ � s7 Y
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 I Address
License Law for the following reason (Section.7031.5, Busi- City Tel.No.
ness and Professions Code): z'2 6 1, rJ A
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project o 0 0.o 0 5
(Section 7044, Business and Professions Code). 2'- 17
2'5 0
CONSTRUCTION LENDING AGENCY o o 7 2 Q L
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.).
01. 13-82
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 inspection purposes.
I pie
ignature of Permittee late