HomeMy Public PortalAbout5636 ROSEMEAD BLVD_Plumbing__ %affirm
�'COMPENSATION DECLARATION 7sn867 APLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a' certificate of consent to self C19817(2-80)
insure,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company J, f� ��)) /►
El Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) ABUILDINGDDRESS cE/ � [��i v,7���i 6i�
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE
department. WATER CLOSET LOCALITY
Date Applicant NEAREST
BATH TUB CROSS ST. •�9'�7 �J
CERTIFICATE OF EXEMPTION FROM WORKERS' If I
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved LAVATORY MAIL
ADDRESS
by the permit is for one hundred dollars ($100) or less.) }
SINK CITY TEL.NO. 0
f certify that in the performance of the work for which this DISHWASHER V
permit is ' sued I shall not employ any pe in a anner CONTRACTOR,4V, V. �S�
so as to, eco subject to the or s' pe io CLOTHES WASHER Q
ADDRESS �� ��
Date Applicant
SWIMMING POOL RECEPTOR V
NOTFE"T/APPLICANT: If, a r making this Certif to of CITY W&,414f� /,'TEL.NO. � OW.
Exemption, you should beco subject to the Workers' LAWN SPRINKLER SYSTEM STATE �/ / va
Compensation provisions of the Labor Code, you must forth- LICENSE NO. */t9,9Q CLASS
with comply with such provisions or this permit shall be WATER HEATER e
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PROCESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL �® VALIDATION
ness and Professions Code,and my license is in full force and DATE ��7
effect.
FINAL
License Number O / LcyC�lass Q Q� BY -
Contract
'❑ �� � ��
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
Lic.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. 6 5 3 A
ness and Professions Code):
Ell, as owner of the property, am exclusively contracting ; 0 0 0 0 0
with licensed contractors to construct the project
(Section 7044,Business and Professions Code). o o 2 4 5 J
CONSTRUCTION LENDING AGENCY 0 •� i'
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regu 'ng Plumbing,•and hereby
authorize reprsenta Ives of s unty to enter upon the
above- nti ed p perty nsp - n pur
fore of Permittee U Date