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Home My Public Portal About5725 ROSEMEAD BLVD_Plumbing__ ION Wdthat I have a certificate of consent to 20-0026 APW9189 APPLICATION FOR PLUMBING PERMIT lJ I hereby affirm that I have a certificate of consent tc self insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) Policy No14q�Q- Company COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDINGADDSS ` [7 ❑ Certified copy is filed with the county building Inspection `- dep rtment. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant / WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. 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($100)or less.) LAVATORY OWNER I certify that in the performance of the work for which this permit MAIL Is Issued, I shall not employ any person in any manner so as to SINK ADDRESS become subject to the Workers'Compensation Laws. DISWASHER CITY 1&09IC16 TEL.NO. Date Applicant CLOTHES WASHER CONTRACTOR ` NOTICE TO APPLICANT: If, after making this Certificate of 62! A ��• Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR �� ) provisions of the Labor Code,you must forthwith comply with such ADDRESS Z 4 provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO.G�� } CIL I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER STATE / LIC. C (commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NOs .56 7 CLASS (� Professions Code,and my license Is in full force and effect. /�/�. OUTLETS OVER / Li DISTRICT NO. PROCESSED BY a License Number•��y V-7 Lic.Class Oe 5 PER SYSTEM J ; U FINAL DATE VALIDATION DATION W ICL Contractor ��/ Date r J7/-- ` f!] I/v�/y+. T a ❑ I am exempt under Sec. zz; BY FINAL r74 1 a B.&P.C.for this reasoncow 35307 _ 68.48 Date: Plan check fee I A 1111116 1 ITENS Signature PLUMBING PERMIT ISSUING FEE$ p2 TOTAL 68.48 ❑ TOTAL FEE CHECK 68.48 rV[. SINGLE FAMILY Plan check applicant CHAI'1 E .00 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 � ��tJtJiJi 1 Code): /9 El 1, Tel.No. V LI/23/7 I,as owner of the property,will do the work and the structure 6644 1 AM 9 14 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 and State laws regulating Plumbing, and hereby authorize representatiy of this County t e t r upon the above-mentioned propert F' spectlon rp [/�,) SEE REVERSE FOR EXPLANATORY LANGUAGE SI nature of P rmittee Date 1rm that I have of c.msATION 76AO681)Pw9/89 APPLICATION FOR PLUMBING PERMIT I h3reby affirm that I have a certificate of cahseht•to self insure, 76A667A or a certificate of 1W.Vorker's Compensation"Insurance, or a certified copy thereof(Sec.3800 Lab.C.) y No /acompany • � _ �,�� COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. ` of Certified copy is hereby furnished. ADDRESS �1? ' FOR APPLICANT TO FILL IN(PRINT OR TYPE) r .00, �•i,2/1 Certified copy is filed with.the county building Inspection/ J epartmen / NUMBER FIXTURE OR ITEM @ FEE C//� � LOCALITY C Date .-/ Applica Af WATER CLOSETNEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. 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($100)or less.) OWNER I certify that in the performance of the.work for which this permit LAVATORY is issued, I shall not employ any person in any manner so as to , SINK ADDRESS become subject to the Workers'Compensation Laws. DISWASHER CITY TEL.NO. Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after making this•Certificate of �v t�Leiv Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS ;),oit�� s provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM /T LICENSED CONTRACTORS DECLARATION CITY O�.at.Ov� ;/� TEL.N��—/�9 } I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER ®. STC (commencing with Section 7000)of Division 3 of the Business and LICENSE NO. �/ 9.f o CLASS Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS DISTRICT NO. PROCESSED BY OUTLETS OVER _ ` �p /� �.r�-.rte a r 5 PER SYSTEM Ott License Number Lie.Class ,v' 4I a E V FINAL jLLJ // DATE 7/L J VALIDATION� 1 Lei a��T . � Contra<rr�"� r/n/W 4' 0y�ate FINAL 3 ('f_, El am exempt under Sec. BY B.&P.C.for this reason b TO AL 1 :1 9= 10 H Plan check fee { Date: .:, CHECK ��{.-`'a irl Signature PLUMBING PERMIT ISSUING FEE$ CHANGE a01 ❑ i TOTAL FEE / Q SINGLE'FAMILY Plan check applicant 0000-00011 611 1/94 HOME OWNER-BUILDER DECLARATION Name si 1 r i AM 1 ,'I•G .,. I hereby affirm that I am exempt from the Contractor's License Law _� 7 s s-1: 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 Lender's Address I certify that I have read this application and state that the above Information is co c I agree to comply with all County ordinances and State I s r gulatl Plumbing, and1hereby authorize representati s this 2§ to e u he ove-mentioned property f in ectlon purp es.. ` 9 SEE REVERSE FOR EXPLANATORY LANGUAGE S1 ature of PWRI a Date