HomeMy Public PortalAbout5707 ROSEMEAD BLVD_Plumbing__ { WORKER'S I. COMPENSATION
ate of consent to ;�A Pw9%58- APPLICATION FOR PLUMBING PERMIT �.
I herebq'affirm that 1 have a certificate of consent to self Insure,
or a certificate of Worker's Compensation Insurance, or a certified
cAo/pit�hereof(Sec.3800 Lab.C.)
i1ov
CY N, �, �Company / COUNTY OF LOS ANGELES DEPT.-OF PUBLIC WORKS i,, DEPT.OF PUBLIC WORKS DIV.
ElCertified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
DDRE 6 �l/ ,
Certified copy is filed.with the county Idi spe Ion
daps, ant. NUMBER FIXTURE OR ITEM ® FEE
LOCALI
Date - Applicant WATER.CLOSET ,
' NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE BATH TUB ASSESSOR
MAP BOOK PAGE PARCEL
(This section need not be completed if the work Involved by the SHOWER -
permit is for one hundred dollars($100)or less.) OWNER
I certify that in the performance of the work for which this permit LAVATORY
Is issued, I shall not employ any person in any manner so asto MAIL
become subject to the Workers'Compensation Laws. . ADDRESS
DISWASHER TY 00, TEL.NO.
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If; after making this Certificate,of CONTRACT R
Exemption,you should'become subject to the Workers"Compensation SWIMMING POOL RECEPTOR ADDRESS
,provisions of the Labor Code,you must forthwith comply with such'
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO –,:§/� }
WATER HEATER IL
I hereby affirm that I am licensed under provisions of Chapter 9 F a
(commencing with Section 7000)of Division 3 of the Business and STATE LIOiL•�• a
OAS SYSTEM OUTLETS LICENSE NO. �p' Q�Qa CLQ
Professions Code,and my license is in full force and effect. ���a?�
OUTLETS OVER DISTRICT NO. PROGtES'?;ED BY Q
90�D 5 PER SYSTEM 1 * r C
License Number. Lid.Class _
FINALVATL-� kTIOI
�1 DATE 3..r,b �
Contra L Date 1'HECK v'i e L c
❑ i am xempt and Sec. BY FINAL CHANGE ,CO3
B.&P.C.for this reason
Date: Plan check fee / , _
Signature PLUMBING PERMIT ISSUING FEE$ �f ? O
f r�
❑ TOTAL FEE /f/,. �>r 13977 1 AM 9%.53
.ns`Y.='
SINGLE FAMILY Plan check applicant r „
HOME OWNER-BUILDER DECLARATION Name
1-hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5, Business and Professions Address
Code):
❑ City Tel.No.
I,as owner of the property,will do the work and the 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
r
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
representatives of this County to enter upon the above-mentioned
prop ell - ri epjtctio urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
3•
dt—ma of Parmhlaa mte
WORKER'S COMPENSATION DECLARATION 8 DPW 9/89 APPLICATION FOR PLUMBING PERMIT LJ
76A6B
I hereby�laffirm that I have a certificate of consent to self insure, 7BA667A
or a certificate of Worker's Compensation Insurance, or a certified
c �of(Sec.3800 Lab.C.)�(/9pCOUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS. : DEPT.OF PUBLIC WORKS DIV.
7 Po icy N �ompany r
❑ Certified co ' I 1
copy is hereby furnished. O
"" FOR APPLICANT TO.FILL IN(PRINT.OR TYPE) BUILDINGgDDRESS
Certified copy.le filed with the county building Inspection '
r department: NUMBER FIXTURE OR ITEM ® FEE
� � LOCALITY
AM
Date Applicant WATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTION.'FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work Involved by the SHOWER
MAP BOOK PAGE PARCEL
permit Is for one hundred dollars.($100)or'less.) OWNER
LAVATORY
I certify that In the performance of the work for.which this permit MAIL
Is issued, I shall not employ any person in any manner so as to SINK ADDRESS
become.subject to the Workers'Compensation Laws.
DISWAS HER C TEL.NO.
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code,you must forthwith comply with such
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEMEo t10
LICENSED CONTRACTORS DECLARATION CITY TTER a
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
(commencing with Section 7000)of Division 3 of.the Business and STATE LIL. C
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. 6p CL43,S•y C
OUTLETS OVER DISTRICT N6 t_,a 00CIUSMb BY jY
�D 6 5 PER SYSTEM
License Numb er Lic.Class�/ "� D� � i,., - 294.60
��O ����J L
FINALDATE VALIDA'TI{ON "
U.
Cont Date 1�— MINE INE 50 s 70Cr
'
FIN
❑ I am empt under c: BY AL CHECK 9513.709
B.&P.C.for this reason ' CHANGE .00
Date:
Plan check'fee
Signature PLUMBING PERMIT ISSUING FEE$ � , O�
TOTAL FEE —�� i/16/95
Pian check applicant a 9103 s 8 a 45
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name••
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Address
Code):
❑ City Tel.No.
I,as owner of the property,will do the work and the 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
r
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 1
and State laws regulating Plumbing, and hereby authorize 1
representatives of this County to enter upon the above-mentioned
propo s ct n p e SEE REVERSE FOR EX LANATORY LANGUAGE
S gna ure Permittee Date