HomeMy Public PortalAbout5771-5801 ROSEMEAD BLVD_Plumbing__ WOR�COMPENSATION DECLARATION 7B�ADPw9/89 gppLl�ION ,FOR PLUMBING PERMIT
I hereby affirm th ave a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance,or a certified
copy:thereof(Sec.3800 Lab.
C.)
Policy No. �� �a Company 10 1 c COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
❑ Certified copy Is hereby furnished. �Q .
Certified copy is filed with the c ndl n y bu1Rl n ' FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING / n/�
ADDRESS���( �v ��
department. NUMBER FIXTURE OR ITEM ® FEE LOCALITY
Date —Z� Applicant WATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTION FRO WORK RS' BATH TUB CROSS ST:
COMPENSATION INSURA CE , ASSESSOR
(This section need not be completed if the.work Involved by the SHOWER MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) LAVATORY OWNERCV�� vc�7" ,
I.certify that in the performance of the work for which this permit I&
is Issued, I shall not employ any person in any manner so as to SINK ADDRESS ��'l�r+v r
become subject to the Workers'Compensation Laws.
DISWASHER CITY TEL.NO ,_
MLLI
Date NOTICE TO APPLICANT:pplicant If, after making this Certificate of CLOTHES WASHER CONTRACTOR `I4aV—
Exempti0
n,you should become subject to the Workers'.Compensation SWIMMING POOL RECEPTORfNe;
provisions of the Labor Code,you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION WATER HEATER CITY, �.�NG TEL.NO. a
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS 0 LICENSE NO. CLCASS
Professions Code,and my license is in full.force and effect.
OUTLETS OVER DISTRICT NO ZSCESSED BY I=
5 PER SYSTEM t/d ,p Q
/JimLicense Number .33Gt�T�!f LIM Class G 3� As
, J
of FINAL
`
ContractorDPJ - Date DATE 7 Va- RATION 1712aaU
1 ITEMS rn
❑ I am exempt under Sec. t FINAL Z
BAP.C.for this re n BY TOTAL 191.25 —
Plan
9 1 m:ter c3
Date: Plan check fee D _ CHECK 191.25
Signatu ' PLUMBING PERMIT ISSUING FEE$ •F �' CHANGE a I
_121TOTAL FEE
Plan check applicanQVA �'�;,�^'��;gym""'
3INGLEFAMILY ,, r ��� � , -,G -L 1 � 4,_
HOME OWNER-BUILDER DECLARATION Name f ���1 '� Y�•- o J�.:.J" A&9$a•e °L
1 hereby affirm that I am exempt from the Contractor's License Law �� til- -�v r'..' -
for the following reason(Section 7031.5,.Business and Professions Address � 33117 395.5111
Code): '
CityTHEW. - 1 ITEMS
1,as owner of the property,will do the work and the structure
is not-intended or offered for sale(Section:7044, Business TOTAL 395.50
and Professions Code). ' I ! , CHECK 3695.SO
CONSTRUCTION'LENDING AGENCY -- v�"" /
I hereby affirm that there is a construction lending agency for the CHANGE of IL{.
performance of the.work for which this permit is issued(Sec.3097,
civ.C.) I]C17t}—E�OQ 1 4l22lf 1
Lender's Name my2A &WIC. Or_ CAWfo"lk-
lO � E 582 1 AIS 10�14
Lender's Address T3 . ST. � L
1 certify that I have read this application and state that the above pop.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