HomeMy Public PortalAbout5633 ROSEMEAD BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in- 20-0026 DPW 4/90 ,
suc�,or certificate of Workers'Compensation Insurance,or a 76A667A
certified copy thereof(Sec. 3800, Lab. C.) �jL JII
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy Na.1 Company
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE)
❑ Certified copy is filed with the county building inspection ADDRESS NUMBER FIXTURE OR ITEM ��`'�c`.•0!It /f
department. @ FEE LOCALITY `
Ddfe 2'2 Applicant fvA Sk!:nN' WATER CLOSET(TOILET) 10 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER -mac/ioL
(This section need not be completed if the work involved by MAIL _
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS y c s f tiZ f_ —
I certify that in the performance of the work for which this per- i
SINK
mit is issued, I shall not employ any person in any manner so f�� CITY -17
TEL. NO.
as to become subject to the Workers'Compensation Laws. DISHWASHER Y
CONTRACTOR e
Date_7 —Applicant CLOTHES CLOTHES WASHER ADDRESS C'' ss
NOTICE TO APPLICANT: If, after making this Certificate of Ex- �" `� • •''yk �� y
em tion,you should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR
P Y I P CITY ., TEL.NO.
G"
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS �'1' e 1 3,
ly with such provisions or this permit shall be deemed revok- STATE �f-`-, LIC.
ed. WATER HEATER LICENSE NO. J �j -CLASS
LICENSED CONTRACTORS DECLARATION GAS SYSTEM OUTLETS DISTRICT NO. ROCESSEb BY
I hereby affirm that I am licensed under provisions of Chapter
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
5 PER SYSTEM DATION o
and Professions Code, and my license is in full force and ef- FINAL aiwr r 107o�o�
fect. f1 d[7CF RIR DATE
License Number s1 Lic. Class A). �� ( "l%
s 1 •E,,:r FINAL IT-Cris
Contractor._ Ccs S>� ;5%i Date 2 Z'G� {�'� BY TOTAL 107 o S,+3 C
I am exempt under Sec. CEECK 107.80
B.BP.C. for this reasonrAN E W
_ c Plan check fee CHANGE�'��� oQfl�
Dat • Z c �� PLUMBING PERMIT ISSUING FEE$
Signature TOTAL FEE 10000-0031 2/20/9$
IN E FAMILY o-+
HOME OWNER-BUILDER DECLARATION Plan check applicant 4`923 1 PH 12 38
I hereby affirm that I am exempt from the Contractor's License NameL�, r-57-6 rJ/
Law for the following reason (Section 7031.5, Business and
Professions Code): Address
❑ I, as owner of the property, will do the work and the City ,� /7� `, G� Tel. No.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
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
ordinances andSt fe laws regulating Plumbing, and hereby
authorize/!Pr tativ of this County to enter upon the
above- ntio pr rty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
S' na of Permittee Date