HomeMy Public PortalAbout4359 TEMPLE CITY BLVD_Plumbing__ WORKERS'COMPENSATION DECLARAT{ON affirmnAsoA /7
I hereby that 1 have x certificate of comatt to self c.et,1x-60) APPLICATION FOR PLUMBING PERMIT U
insure,or a certificate of Workers'Compensatlon insurance,or
a certified copy thereof(Sec.3800,Lb.C.)
57fi471r•.. COUNTY OF LOS ANGELES / � � BUILDINOAND SAFETY
Policy MC mpany-Aetna Trig -
C] Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
j--) NUMBER FIXTURE OR ITEM • FEE ADDRESS 43 Temple Cit vd
I@
Certified copy b reed with the county Dntldfng Inspection
^e t WATER CLOSET O LOCALITY Temple Cit.
DateTbDPUcan�mon Rrna Plh�_ -40 5T
BATH TUBCROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER I OWNER H1X80n & Owen Dev.
MAIL
f his section heed not be cons loW K the work involved 2LAVATORY 100 ADDRESS 9843 Klingerman St,
by the pemJt b for one hundred dollen (SI00) or kmCITY MontpTEL.NO.
.) BINK 5Z5_38
}
1 certify that In the performance of the work for which this DISHWASHER
CONTRALTO
permit b fssuad, 1 shag not employ any persue m any mower Q
w u to become subject to the Workers'Compensation Laws. CLOTHES WASHERQ
tVTt
Date ADDRESS 4265 N. Baldwin Ave.
Applicant SWIMMING POOL RECEPTOR U
NOTICE TO APPLICANT: If, after mating this Certificate of CITY mrintp- TEL.NO —
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM
Compensation provisions of the Labor Code, you must forth- LICENSE NO. 231 741 cLase C36-20
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PRO EBBED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter B PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Buss- FINAL Q �Gy-q/ VALIDATION
nm and Professions Code,and my license Is to full force and DATE 7 O
effect.
License Number231 741 1.11.0m, C36-20 FINAL
Br
Comnctof)tIPnRrnn Pl "Su 6116.1o81- /bs9
OI am exempt from the licensing requirements as 1 am a Plan check fee (/
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE 11
acting In my professional capacity (Section 7051, Btu• 17 -Qb
Inns and Professions Code). TOTAL FEE
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
1 hereby affirm that 1 am exempt from the Contractor's Address
License law for the following reason (Section 7031.5. Busi- Icity TN.No. :20050A
am and Professions Code):
0 1, as owner of the property, sm exclusively contracting # • • • • • $
with licensed contractors to construct the project 2 • * 2500
(Section 7044,Business;and Professions Code).
CONSTRUCTION
hereby afflrmgtreconswiioloading agency 0 623-81
for the performance of the work for which this permit is
issued(Sec.3097,CW.C.).
Lender's Name
sander's Address
1 certify that I have read this application and state that the
she"Information Is correct.I agree to amply with on County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State lam regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
e o en property forInspectionpurposes.
-u C_�L1w. 6/16/R7
skipulliT of PrIi
Pat 1"" Date