HomeMy Public PortalAbout5617 ROSEMEAD BLVD_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I Fteaeby, affirm that I have a certificate of convent to self,n- N1DPW 4/W
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lure or o certificate of Workers Compensation Insurance,or a
certified copy thereof (Sec 3800 Lab C
Policy NoWC14 L "pony L&a C COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Certified copy is hereby furnished
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN(PRIM OR TYPE) CRESS S760 V-4� � OL V
department I� .,�,�T NUMBER FIXTURE OR ITEM ® FEE LOCALITY
Date raw NST
Applicant TW L "cTrN WATER CLOSET(TOILET) NEAREST _
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work Involved by MAIL
the permit Is for one hundred dollars ($100)or less ) V ADDRESS
I certify that in the performance of the work for which this per- 3 CITY TEL NO
mit is issued, I shall not employ any person in any monner so TAX)• as to become sublect to the Workers'Compensation Laws DISHWASHER CTORRr oo S TiW(,T/
Date Applicant CLOTHES WASHER ADDRESS 'Y L 7 L11
NOTICE TO APPLICANT If after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY C '14 TEL NO T_'f73 CS'SZ
sotion provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok STATE ' �^ LIC p
ed WATER HEATER LICENSE NO CUSS 17
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
0
I hereby affirm that I Incensed under pooft GAS SYSTEM OUTLETS of Chapter p P
9(commencing with Section 7000)of Divisionn 3 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER HOSE BIB FINAL VALIDATION
o-� ss Y
fect �lI/`1
License Number 11 O ' Lic Clanq, 0
FINAL V
contractor U 0 Q1*11i Ta..Lrr7 r 61�r,taQidl-;11 14 EL BY ALLT.i
I am exempt under Sec 33033 71 ju
B 8P C for this reason ITENS W reason Plan [heck fee ,
Date PLUMBING PERMIT ISSUING FEE$ TOTAL 72 _ 751
Signature I_HECK 72.r5
TOTAL FEE
SINGLE FAMILY CHMGE ,CI!I
ROME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor s License Name
Law for the following reason (Section 7031 5, Business and 130133-131301 5/2/5.,Professions Code) ,address
I, as owner of the property, will do the work and the City
- Taj No 5253 1 Ah 9:,t-,
structure is not intended or offered for sole(Section 7044
Business and Professions Code) ► ,
CONSTRUCTION LENDING AGENCY
I hereby affum that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec 3097 Civ C )
MLender's Nome —�
Lender's Address 1
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 representatives of this County to enter upon the
above oned property for mspecI Our
Q/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig natu of Permittee Date