HomeMy Public PortalAbout5799 ROSEMEAD BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
1 hely 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 coy thereeoff(�(Sec. 3800 Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy Nod / S company.
Certified copy is hereby furnished. to—(—,) ( t BUILDING:, �t7/v
❑ FOR APPLICANT TO FILL JN PRINT OR TYPE ADDRESS l/
Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM @ FEE z
tion department. LOCALITY -
Date Zr Z Appli4 WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER:
(This section need not be completed if the work involved by SHOWER.
MAIL
the permit Is for one hundred dollars($100)or less.) ' LAVATORY ADDRESS
I certify that in the performance of the work for which this '
permit is issued,I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER ���
CONTRACTOR sI �v�/
Date Applicant CLOTHES WASHER ADDRESS l Z3 K
NOTICE TO. APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY. �� otir TEL
Compensation provisions of the Labor Code,-you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STA7E Ej LIC. p
deemed revoked. WATER HEATER
LICENSE NO: 4'133 ! CLASS (7
LICENSED CONTRACTORS DECLARATION DISTRICT NO: PROCESSED BY
GAS SYSTEM OUTLETS
I hereby affirm that I am licensed under provisions of Chapter 9 141,10
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 15 PER SYSTEM. FINAL VALIDATION
/` DATE Q
License Number `'� ��� Lic. Class C7
j(� FINAL lZ
Contractor J�� �d "�r'sDate �� BY
❑ I am exempt under Sec.
B.BP.C. for this reason: ® Cn
Plan check fee
• Date. PLUMBING PERMIT ISSUING FEE$ tv
Signature
TOTAL'FEE 60
SINGLE FAMILY
Plan check applicant
HOME OWNE (i��.
R-BUILDER DECLARATION Name _ r.
I hereby affirm that I am exempt from the Contractor's License Address +-i rk j
Law for the following reason (Section 7031.5, Business and i r: ,
Professions Code): City Tel. No. 1 I::1°(b
60
❑ I, as:owner of the property,-will do the work and the TV I- . 1-.�26.
structure is not Intended or offered for sale (Section ,
7044, Business and Professions Code). CHECK
CONSTRUCTION LENDING AGENCY r;t ANG;l o'j i
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sea. 3097,Civ. C.). ,tlij incl'm I _I;
QJ,.- . �:.
Lender's Name A!¢I 5`;s ;
�.L.
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 representatives of this County to enter upon the
above-mentioned'property or inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date