HomeMy Public PortalAbout5805 ROSEMEAD BLVD_Plumbing__ ~WORKERS'COMPENSATION DECLARATION 20-0026 DPW 4/90 APPLICATION FOR PLUMBING PERMIT
° I hereby, affirm that I have a certificate of consent to self in- 76A667A
s°sure,or a certifiCate of Workers'Compensation Insurance,or a
certified copy thereof(Sec.3800, Lab. C.)
y �� P y STAM Fj&j�_ COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Polic No. Com an � i ,
Certified copy is hereby furnished. BUILDING
F71 Certified
APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the county building Inspection ADDRESS t/p—
department. ^� f NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date 2S-:yo_Applicant�f J � lrJ WATER CLOSET(TOILET) d NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION MURANCE SHOWER OWNER
(This section need not.be completed if the work Involved by MAIL
the permit is for one hundred,dollars($100)or less.) LAVATORY' ADDRESS
I certify that in the performance of the work for which this per- SINK CITY TEL.NO.
mit is issued, I shall not employ any person in any manner so
as to become subject.to.the Workers:Compensation Laws. DISHWASHER
CONTRACTOR
Date. Applicant. CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If,.after making this Certificate of Ex-
em tion,yo should become sub'ect'to the Workers'-Com. en- SWIMMING POOL RECEPTOR
P y I P CITY TEL. N
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC:
ed. WATER HEATER' LICENSE NO. cam
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSEb BY
Thereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ,!/O
9(commencing with Section 7000.)of Divisi6n 3 of the Business OUTLETS OVER 5 PER SYSTEM
and Professions Code, and my license is in full force and ef= FINAL VALIDATION
fact. // HOSE BIB DATE l Z CL
License Number E2�s204? Lic. Class Is. [
CA�v FINAL V
Contractor. 244 Date BY pGCT e ff °C
I am exempt under Sec. _ C
❑
B.BP.C. for this reason 3303 1�0eo W
Plan check fee 1 ITEMSCL
Date: PLUMBING PERMIT ISSUING FEE$ TOTAL 120507
Signature -
SINGLE FAMILY TOTAL FEE rj2 0 j j) CHECK 120.50
HOME OWNER-BUILDER DECLARATION Plan check applicant CHANGE .00
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section'7031.5, Business and
Professions Code): Address 0000-0001 5/ 9/96
F1 I, as owner of the property, will do the work and the City Tel. No. 662 1 AM10O-55
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). ►
CONSTRUCTION LENDING AGENCY
I hereby affirm that.there is a construction lending agency for
the performance of the work for which this permit is issued 1
(Sec. 3097, Civ. C.).
Lender's Name '
Lender's Address
I certify chat I have read this application and state that the
above information is correct. I agree to comply with all County ► '
ordinances and State laws tegulpting Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
i '