HomeMy Public PortalAbout6029 ROSEMEAD BLVD_Plumbing__ ,Wk1*0RKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
by o0irm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A ILJ'
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
F-1Certified copy is filed with the county building inspec- ADDRESS
tion department.
NUMBER FIXTURE OR ITEM ?a FEE LOCALITY
Date Applicant 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
the permit is for one hundred dollars ($100)or less.) LAVATORY } 7 ADDRESS
MAIL
G
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. O
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER
NOTICE APPLICANT: If, afte moking this Cer i e of ADDRESS
Exemption, you should become subject to theWorkers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION GAS SYSTEM OUTLETS D�RICT NO— PROCES$Ep BY
//
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER U
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ? / }
` VALIDATION a
DATE0
License Number Lic. Class U
FI
Contractor Date B Q
❑ -- 0
am exempt under Sec. W
B.&P.C. for this reason ® CLCn
Plan check fee
Z
Date: PLUMBING PERMIT ISSUING FEE$ � w
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the
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
(Sec. 3097, Civ. C.).
Lender's Name
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 for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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