HomeMy Public PortalAbout5751-5757 ROSEMEAD BLVD_Plumbing__ WORCOMPENSATION DECLARATION DPW 9189
76A667 gPPLI 'ION FOR PLUMBING PERMIT
I hereby affirm th ave a certificate of consent to self Insure, 7tiA8fi7A
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C
Pollcy No.-I ��f+ omp�ny Y��N (/l �� 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) BUILDING
❑ Certified copy is filed with the coui ins n ADDRESS `J fes/
department. pq NUMBER FIXTURE OR ITEM @FEE1-1 LOCALITY
Date®� Applicant WATER CLOSET NEAREST !� J 1
CROSS ST. V
CERTIFICATE OF EXEMPTION FROM OAK RS' BATH TUB
COMPENSATION INSURAN E ASSESSOR
(This section need not be completed if the work Involved by the SHOWER MAP 800K PARCEL
PAGE
permit is for one hundred dollars($100)or less.) �OWNER l
I certify that in the performance of the work for which this permit LAVATORY
Is issued, I shell not employ any person in any manner so as toMAIL �_ d
SINK ADDRESS 1 �/
become subject to the Workers'Compensation Laws.
DISWASHER CITYTEL.NOW -95
Date Applicant CLOTHES WASHER N
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTORPr
!
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS fill '
provisions of the Labor Code,you must forthwith comply with such �y oa+
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO. A 3 3�� }
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER ��/fCL
`P
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM �, OUTLETS u v IL CENSE NO. 3� CLCASS G.�j
Professions Code,and my license is in full force and effect.
OUTLETS OVER DISTRICT NO. _.-PROCESSED BY Ix
'^ 5 PER SYSTEM t�� 9!� �/
License Number 53(k3A15 Llc.ClassC �7tA FINAL VALIDATION
Contractor De I e- Date �-Z2DATE � �v EL
❑ I am exempt under Sec. BY AL
B.&P.C.for this reason
Date: Plan check fee �� 7
Signatu
PLUMBING PERMIT ISSUING FEE$ � �•
❑ TOTAL FEE -
Plan check applicant
SINGLE FAMILY —•---+ .,�--= rs.-�-----=
HOME OWNER-BUILDER DECLARATION Name l
I hereby affirm that 1 am exempt from the Contractor's License Law ��_•:~er
for the following reason(Section 7031.5, Business and Professions Address
Code):
City
I,as owner of the property,will do the work and the structure y i4tN.-
Is not intended or offered for saleSection 7044, Business
and Professions Code). ( 1'0=510
a}
CONSTRUCTION LENDING AGENCY N--'('
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.) r nq �.s,e!
Lender's Name "To"I E�1�pp���—�� SAI'Yfi�� _I_I_l ��f_E:i 4�_� �`.'
413 1 e` L=r '''I''+ •i
Lender's Address
I certify that I have read this application and state that t e 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
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE