HomeMy Public PortalAbout6332 ROSEMEAD BLVD_Plumbing__ W affirm
i S`COMPENSATION DECLARATION APPLICATION
/�TION FOR PLUMBING
PERMIT
I hereby; affirm`'that have a certificate of-consent to self in,, 76A667 DPW 4/87 Mr r �rM 1 1r R ry,D V PERMIT
76A667A
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
certified copy thereof:(Sec. 3800, Lab. C:)
Policy No: - - Company COUNTY OF LOS ANGELES DEPT. OF P.UBLIC_WORDS. ;
Certified copy is lierebyrf'nished'
.❑-. l!•• i ► FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDINGADDRESS 04
Certified copfy"is'filed with the county building inspection ADDRESS ��
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date ' Applicant 1 WATER CLOSET(TOILET) NEAREST /
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB' CROSS ST:
COMPENSATION INSURANCE SHOWER OWNER all- d y
( P Y MAIL
This section need not be com leted.if the work involved b
• .. r
the permit is for,one hundred dollars ($100)or less.) LAVATORY ADDRESS 2 r, V
I certify that in the performance of the work for which this per- /�
,mitis issued, I;shall riot employ any person in any.manner so - SINK VV. h�� U ��. CITY e� TEL. NO.
as to become subject to-the Workers Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER /-
NOTICE TO APPLICANT:':If, after making this'Certificate of Ex- ADDRESS %f r ( /C7t�,,n
emption,you should become subject to the Wo.r•kers'Compen- SWIMMING POOL RECEPTOR _„ �
CITY ^ _ ✓►T TEL. N\O_ )41�
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM vv ll v r
ly with such provisions or this permit shall be deemed revok- STATE �? LIC.
ed. • WATER HEATER LICENSE NO: .j CLASS
LICENSED CONTRACTORS DECLARATION, DISTRICT NO. ESSED BY
I hereby affirm'that I am licensed under provisions of Chapter GAS,SYSTEM - OUTLETSi i
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM
feet. FINALq VALIDATION �
DATE
License Number' _j Q �^ Lic. Class V
FINAL
Contractor.COT- fan► Date R- Id'S'cS BY O
E ,I am exempt under Sec. U
B.&P.C.,for' this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature `/M �Y7 ,L�
TOTAL FEE
SINGLE FAMILY Plarrcheck a licant
HOME OWNER-BUILDER DECLARATION PP
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
I, as,owner of the property, will do the work ond.the City Tel. No. . 04 7.0
structure is not intended or offered for sale(Section 7044, o,o 0
Buo o s
siness and Professions Code). # 5
J
CONSTRUCTION LENDING AGENCY
;a 4050
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
Signature of ermittee Date