HomeMy Public PortalAbout6037 ROSEMEAD BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION 76AG67A
I hereby affirm that I have a7 certificate of consent to self c6 617(2-66) APPLICATION FOR PLUMBING PERMIT
insure,or a certificate of Workers'Cotqpensation Insurance,or
a certified copy thereof(Sec.38I
0al3.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Compan �
mak
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
Certified copy is filed with the co my bu'Idin NUMBER FIXTURE OR ITEM FEE ADDRESS
p g inspection LOCALITY
de rtQQ�t�nntff�� A„�J WATER CLOSET p
ate WM)APplican S NEAREST
BATH TUBCROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
LAVATORY
MAI L a
/ ��
(This section need not be completed if the work involved �'� ADDRESS
by the permit is for one hundred dollars ($100) or less.) SINK CITY TEL.NO, / 0
I certify that in the performance of the work for which this DISHWASHERn �O Ix
O
permit is issued, I shall not employ any person in any manner CONTRACTOR 0
so as to become subject to the Workers'Compensation Laws. CLOTHES WASHERU
ADDRESS
Date Applicant 9L
SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO I rn
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE .) LIC.
Compensation provisions of the Labor Code.,you must forth- WATER HEATER LICENSE NO. �odJ CLASS
with comply with such provisions or this permit shall be
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. _/ PROCESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 15 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code,and my license is in full force and DATE
effect. A 11
License Numb er% Lic.Class FINAL
BY
Contracto-•t u l�l f�I A1C/ Date
❑ I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
Lic,or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section 7031.5, Busi- City Tel.No. 7362 _6 r
ness and Professions Code):
IDI, as owner of the property, am exclusively contracting o e o 0 0 .71
with licensed contractors to construct the project
(Section 7044,Business and Professions Code). 2 a y
CONSTRUCTION LENDING AGENCY
.1.O 2 ko - C
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 3
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
OSignatef P r Vee Date