HomeMy Public PortalAbout5128 ROSEMEAD BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION 76A667A
I hereby affirm that I have a' certificate of consent to self ce 917 (z-s0) APPLICATION FOR PLUMBING PERMIT
insure, or a certificate of Workers'Compensation Insurance,or
a cert copy thereo (Sec. 3&00,Lab.C.) / v
1jJ7s�p - T� FUNd COUNTY OF LOS ANGELES BU14DING AND SAFETY
Policy No. Company-' lu, p
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM FEE
department ;lE�+ LOCALITY! IL
6�i_— WATER CLOSET 7� NEAREST
Date_1—,�pplicant_,a ��
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
MAIL �T
(This section need not be completed if the work involved LAVATORY ADDRESS > 1, d
by the permit is for one hundred dollars ($100) or less.) SINK clTv TEL.N 3--Y3 0
I certify that in the performance of the.work for which this DISHWASHER
permit is issued, I shall not employ any person in any manner CONTRACTO 866-
I Mv h O
so as to become subject to the Workers' Compensation Laws. Ll CLOTHES WASHER / C
ADDRESS V
Date Applicant SWIMMING POOL RECEPTOR F�� W
NOTICE TO APPLICANT: If, after making this Certificate of CITY �u d�-.J TEL.NO.^
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM Z
p J STATE LIC.
Compensation provisions of the Labor Code, you must forth- / LICENSE NO.. 3 CLASS
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked. GAS SYSTEM 15'OUTLETS
DISTRICT NO. P OCESSED Y
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
/ 9, (commencing with Section 7000) of Division 3 of the Busi- FINAL ' VALIDATION
ness and Professions Code, and my license is in full force and DATE ( j,yl;��dy-
effect. /
�`�� FINALl
License Numb1415� Lie.Class p BY
Contract `M Date I � Ofl .
�, ❑ I am exempt from the licensing requirements as I am a Plan check fee /,3!`'/
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE 0
Lie.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): ;;_9 2 6 1.6 A
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project # o. 0 0 0 0 5
(Section 7044, Business and-Professions Code).
'2 0 20850
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 0 0 2 0 Loi:5 0 5
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). 0 1, 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 ins on purposes.
ignature of Permittee ate