HomeMy Public PortalAbout5439 ROSEMEAD BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I h&r by, affirm that I have a certificate of consent to self in- 76A667
A PW 4/90
sure,or a certificate of Workers'Compensation Insurance,or a
certified copy thereof (Sec. 3800, Lab. C.)
(( [[ COUNTY OF LOS.ANGELES DEPT. OF PUBLIC WORKS
Policy No. p
�mony ISMAt
Certified copy is hereby furnished. 11JJFOR• BUILDING
APPLICANT TO FILL IN(PRINT OR TYPE)
❑ Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY ? LGA
WATER CLOSET(TOILET,)
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE RCIE
WNER
(This section need not be completed if the work involved by /S p MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which This per- SINK ��, CITY TEL. NO.
mit is issued, I shall not employ any person in any manner so
as to become subject to the Workers'Compensation Laws. > W=MMM���f��r4
ONTRACTOR
Date Applicant CLOTHES WASHER ti
ADDRESS
NOTICE TO APPLICANT:If, after making this Certificate of Ex- 54 OR ��
emption,you should become subject to the Workers'Compen- CITY ` 1�
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEMS %AT!
ly with such provisions or this permit shall be deemed revok- I STATE l / LIC.
ed. ® WATER HEATERI' LICENSE NO. l / GLASS. Id
LICENSED CONTRACTORS DECLARATION `� DISTRICT NO. PRQCESSED BY
GAS SYSTEM OUTLETS / ! ��
I hereby affirm that I am licensed under provisions of Chapter - -
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER l/ ��� ��
5 PER SYSTEM S`'�`'=;
and Professions Code, and my license is in full force and ef- FINAL yp),�bATION
tett. _ �.'k .+Y�
/ � HOSE BIB � �+ d DATE _
License Number / q1C/1 Lic. Class �J� —_ c i 0
J i? L✓tai 5k. FINAL V
Contractor R%*av p �o1�ate '"l— BY r•r-•t _ pe
V �� 70 o
I am exempt under Sec. a,� Gka,• a 0 -_ zin x wV
B.&P.C. for this reasonJ� , _
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ ® "':• - r Z
+1' ?-_• _
Signature TOTAL FEE 3s ?
SINGLE FAMILY "
HOME OWNER-BUILDER DECLARATION Plan check applicant (3"
T7
I hereby affirm that I am exempt from the Contractor's License Name _ _
Law for the following reason (Section 7031.5, Business and r
Professions Code): Address l"l'A(_..
I, as owner of the property, will do the work and.the City Tel. No. 'CHECK
structure is not intended or offered for sale(Section 7044, !_,;AA:
Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY 9 „
I hereby affirm that there is a construction lending agency for + OCI
the performance of the work for which this permit is issued "". '
p - ti6asi=�'y.
(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
ordinances and State laws regulating Plumbing, and hereby
authorize re res entatil s of this County to enter upon the
above- e e erty for inspection purposes.
0 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of'Permittee Date