HomeMy Public PortalAbout5741 ROSEMEAD BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPUCIr VON FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
Insure, or a certificate of Workers'Compensation Insurance, '76A667A
or a certified copy thereof(Sec, 3800, Lab. C.) �� COUNTY OF LOS ANGELESDEPT.OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished. BUILDING
F1ADDRESS APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Appl igant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER WNERKL
�
(This section need not be completed if the work Involved by MAIL'
the permit is for one hundrod dollars($100)or less.) LAVATORY ADDRESS �7 �� -
I certify that in the performance of the work for which this SINK CITY TEL.NO�
permit is Issued, I shall not employ any person in any manner —807
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOff
Date Applicant CLOTHES WASHER ,� ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY, TEL.NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION I DISTRICT NO. PROCESSED BY
I hereby affirm-that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �O
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
DATE g 4 q Z VALIDATION C
License Number Lic. Class Q
FINAL C
Contractor Date BY Q
❑ F-
I am exempt under Sec. W
B.&P.C. for this reason
Plan check fee z
Date. PLUMBING PERMIT ISSUING FEE$ 7111-0
Signature TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License '
Law for the followingreason action 7031.5, Business and Address _
Professions Code): City Tel. No. i •a -r--r•
❑ I, as owner of the property, will do the work and the t = °
structure is not intended or offered for sale (Section j � ; - I�§
7044, Business and Professions Code). - 5
CONSTRUCTION LENDING AGENCY3
I hereby affirm that there is a construction lending agency for -:hf.t�Q �� }
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Names},T—-I 'J• a/
Lender's Address I 4L AOK15_,
1 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
X�_
ntio d'property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Per ittee ' Date