HomeMy Public PortalAbout6009 ROSEMEAD BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby,affirm that I have a certificate of consent to self in- 26A667 DPW 4/90
76A667A
sure,tlrp certificate df Workers'Ccy-npeasauon Insurance,ora tiUl
"certifie✓4Fopy thereof(Sec. 3800, Lab. C.) j
Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
'F_J Certified copy is hereby furnished. BUILDING /�
FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the county building inspection ADDRLOCALITY ESS y
department. NUMBER FIXTURE OR ITEM @ FEE �•
6
Date Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST. tjlj
COMPENSATION INSURANCE OWNER,
SHOWER
(This section need not be completed if the work involved by MAIL
the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK CITY ' TEL.NO.
mit is issued, I shall not employ any person in any manner so
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date. Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION /� DISTRICT NO. PROCESSEb BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS /
9(commencing with Section 7000)of Division 3 of the.Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM 1
FINAL' VALIDATION
fect. HOSE BIB DATE �` � ?�
License Number Lic. Class a
FINAL
Contractor Date
BY a
F1 I am exempt under Sec. G
B.$P.C. for this reason Plan check fee a
d
ACCT.10
Date: PLUMBING PERMIT ISSUING FEE$ 30
Signature TOTAL FEE �j/�7 3303 43.40
SINGLE FAMILY Plan check applicant 1 ITEMS
HOME OWNER-BUILDER DECLARATION pp TOTAL 43-4113
1 hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and CHECK 43°40
7CHANProfe ions Code): Address
as owner of the property, will do the work and the City Tel. No.
GE °QO
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). 0000-0001 ]/ 4/96
CONSTRUCTION LENDING AGENCY 11110.
5104 � A�l10�,�u
1 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 111101above 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
a ve-me tinned property for 1 s pur
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig t e o ermiftee -1 DIte