HomeMy Public PortalAbout5803 ROSEMEAD BLVD_Plumbing__ .T. 9 �V c&KERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
II hereby affirrtfi' that I have o certificate of consent to self 20-0026 DPW 6/87
n (Sr a}certificafe of Workers'Compensation Insurance, 7GA667A
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished. •'
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS G
tion department. NUMBER FIXTURE OR ITEM
® FEE LOCALITY
Date Appligant WATER CLOSET NEAREST ,y—
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. v / f
COMPENSATION INSURANCE OWNER IF �'
(This section need not be completed If the work involved by SHOWER
the permit is for one hundred dollars($100)or less.) LAVATORY MAIL
.ADDRESS
I certify that in the performance of the work for which.this n
permit is Issued,I shall.not employ any person in any manner SINK O.CITY N _tJ .
so as to become subject to the Workers'.Compensation Laws. DISHWASHER
CONTRACTOR
Date —Applicant CLOTHES WASHER r
NOTICIt TO APPLICANT: If,'after making this Cert' icate of SWIMMING POOL RECEPTOR ADDRESS .UJ7 id
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby off lrm•that.I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER v
and Professions Code,and my license is In full force and effect. 15 PER SYSTEM, FINAL VALIDATION
Z
License Numb �tJ6�er � Lic.Class DATE
Va. FINAL FY
Contractor BY O
I am exempt under Sec. ToUJIiZo
B.BP.C, for this reason Plan.check fee ® CO)
Date. PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE , *-
!
Plan check applicant ;,
SINGLE FAMILY i!.!IAL. 68. •� -
HOME OWNER-BUILDER DECLARATION Namef•3
I.hereby affirm that lam exempt from the Contractor's.License CHECK '=�.40
I
Law for the following reason (Section 7031.5, Business and C:j-��.',i.iv�' rL;,:'
Professions Code): Address
.City Tel. No.
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section +Ir y f _/ t
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY3_=;:,J
! u.z:.
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 poll
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
�5ignature of Perm i' a iDati