HomeMy Public PortalAbout5701-5711 ROSEMEAD BLVD_Plumbing__ WORKER'S COMPENSATION DECLARATION 20112 Pw9/89 APPLICATION FOR PLUMBING PERMIT
I hereby affirm that•I have a certificate of consent to self Insure, 7gp557A
or a certificate of Worker's Compensation Insurance,or a certified
copy thereof(Sec.4 Lab.C.) -;r
_�s�a/L'� COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No arly _
❑ Certified copy is hereby furnished.
FOR.APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING '
❑ Certified copy is filed with:the cc my buil ng ins.action ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date < , AppliCCAL
WATER CLOSET ,0
NEAREST
CERTIFICATE OF EXEMPT N FROM WORKERS' CROSS 3T. �J J
COMPENSATION'INSURANCE BATH TUB ASSESSOR
(This section need not be completed If the work.Involved by the SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) LAVATORY !p o OWNER v
I certify that in the performance of the work for which this permit' e�O MAIL
Is issued. I shall not employ any person in any manner so as to SINK ADDRESS JC)C)
become subject to the.Workers"Compensation Laws."
DISWASHER CITY TEL.NO.
Date Applicant %I CLOTHES WASHER CONTRACTOR;
NOTICE TO APPLICANT: If,after making this Certificate of �U✓rl
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS I O'J " l
.provisions of the Labor Code,you,must forthwith comply.with such
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION _ CnY Y1(1 T& $- a
I hereby affirm•that I am licensed under provisions of Chapter 9 WATER HEATER . .
(commencing with Section 7060).of Division 9.of the Business and STATE LIC. C
Professions Code,and my license Is in full farce and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS �- C
OUTLETS OVER DISTRICT NO. P CESSED BY Q
(��4 5�RSY
License Number Z� Licr Classes G� a7
FINAL j VALIDATION ILI
Contractor t^'� Date 3 I_Cl�- " �w. oma.. . �a �f•S" ��6 DATE 2 a
!/ to
❑ ' �' I S FINAL
I am exempt under Sec. Rt BY &
BAP.C.for this reason
46
Plan check fee
Date:
'Signature
PLUMBING'PERMIT ISSUING FEE$ L� 7� 1 1,r!E,i i
': _ � .
TOTAL.FEE f_j j s
Plan check applicant -7,rc
SINGLE FAMILY "
HOME OWNER-BUILDER DECLARATION Name �'r!.63E-
I hereby affirm that I am exempt from•the Contractor's License Law CHI'1 °'A1
for the following reason(Section 7091.5, Business and Professions Address
Code):
El 1,
Tel.No. I_1 f f 1_,f�tl:i r1,Y1
I,as owner of the property,will do the.work and the.structure
Is not Intended or offered for sale(Section 7044, Business 4711a' AN
And Professions Code).
CONSTRUCTION LENDING AGENCY
1 hereby.affirm that there 191 construction lending agency for the
performance of the work for which this permit is Issued(Sec.9097,
Civ.C.)
Lends Name } 1
• 1�
Lender's Address
I certify that I have re applica..tioh and state that the above ,
infor tion is torte I agre to.comply with all County ordinandes
and St to,laws egulatin Plumbing, and hereby authorize
represen lives o. this C my to enter upon the above-mentioned
P f r inspe lo ur Goes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sit to fPerm ttee Date