HomeMy Public PortalAbout5729 ROSEMEAD BLVD_Plumbing__ "'7WORKERS!COMPENSATION DECLARATION APPLICATION FOR PLU B NG PERMIT
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 �j
insure, or a certificate of Workers'Compensation Insurance, 76A667A lul
or a certified copy thereof(Sec.•3800, Lob. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
policy No. Company
Certified copy is hereby furnished. p G /�
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS S -72.1 /003 t✓W Y✓' S L
Certified copy is filed with the county building Inspec-
tion department. NUMBER ,FIXTURE OR ITEM FEE
LOCALITY
Date Apoligant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER /T N(r! r T)4 A l
SHOWER
(This section need not be completed if the work Involved by MAIL
p ,,�.1 c
the permit is For one hundred dollars($100)or less.) LAVATORY ADDRESS l) 4: U 4CLi o q JSL 3J_/n'J
I certify that in the performance of the work for which this
permit is issued,1 shall not employ any person in any ner SINK /f CITY Q N &A&L r` TEL.NO.
so as to become subject to the Workers'Compensa' n L ws. DISHWASHER C
'LA
r CONTRACTOR �b P(�()
Date pplicant CLOTHES WASHER ADDRESSaA A e
NOTICE TO APPLICANT: If, after making this Certificate of P1
you,
Exem tionshould become subject to the Workers' SWIMMING POOL RECEPTOR
P Y I —te
Compensation provisions of the Labor Code, you must forth-, LAWN SPRINKLER SYSTEM CITY 6-L FrJD 0A-
TEL.NO.
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. LICENSE NO.WATER HEATER vi, J� CLASS,. C
LICENSED CONTRACTORS DECLARATION DISTRICT No. PROCESSED BY
I hereby offirm•that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �j�j� /AlI� �f ��
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER O
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM. FINAL
�l�351 c 3 b DATE VALIDATION
�LCk�� SINS �� O Z C
License Number Lic. Class C:
FINAL
Contractor RJ P""KA (` ate —_ C BY FFC
❑ 1 am exempt.under Sec. LL
- C
B.BP.C. for this reason —aj, +7. •z,7 G
Plan Check fee ® �: �;;+_ I
Date:
PLUMBING PERMIT ISSUING FEE$ o`!'� i. 1_+'�
Signature
TOTAL FEE ZlyQ 1 IIT1 I r ' - .
SINGLE FAMILY
Plan check applicant 171 e
'
HOMEOWNER-BUILDER DECLARATION Name CHANGE
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. f (;4';;
❑ I, as owner of the property, will do the work and the ,,:,,s �
strudture is not intended or offered for sale (Section ® � `� L �: iG-
•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 r
authorize representatives of this County to enter upon the
above-mentioned' erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
c{_- A L
Signature of Permittee Date
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