HomeMy Public PortalAbout4500-4502-4504-4506 TEMPLE CITY BLVD_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76q '
insure, or a certificate of Workers Compensation Insurance CE 817(REV 10/81)
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f (Sevc� 3§p0 La� C ) OFweer COUNTY OF LOS ANGELES BUILDING AND SAFETY
omphny -J y,l% E� ^reby furnished 1 BUIlgr4G, -
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy a filed with the county building inspeo- ADDRESS E
hon deportment NUMBER FIXTURE OR ITEM ® FEE
7` r 0 7 �/ OCAL TY
Dote 1 S Applicant T'N L YS n r7 U la'l.CT"-( WATER CLOSET Jg_ NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS '~`r�'� " BATH TUB v CROSS Si
COMPENSATION INSURANCE
(This section need not be completed If the"rk Imrolved by SHOWER OWNER.7
the permit Is for one hundred dollars($100)or Ins ) MAIL MAK
I certify that in the performance of the work for which this ADDRESS
permit is issued, I shall not employ any Peron in any manner SINKCRY TEL NO 1
so as to become subject to the Worker'Compensation Laws jQL
DISHWASHER
CONTRACTOR
Dote Applicant CLOTHES WASHER
NOTICE TO APPLICANT If offer making this Certificate ofSWIMMING POOL RECEPTOR gDOREss QV OIC L"I
Exemption, you should become subject to the Worker Cln, sopM rMGToi^\m NO /fr
Compensation provisions of the labor Code you must forth- LAWN SPRINKLER SYSTEM — OS'
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO 7- L CLASS 0 3 L
LICENSED CONTRACTORS DECLARATION DISTRKT NO ev
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS /7��
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER t
and Professions Code,and my license is in full force and effect 5 PER SYSTEM FAL
A ! KALI TION
License Number Lic Class G [� 119
FI O
Contractor Date B
❑ 1 am exempt under Sec
B &P C for this reason Z
Plan check fee
Dore
PLUMBING PERMIT ISSUING FEE f
Signature
TOTAL FEE D O
SINGLE FAMILY
[Address
n check applicant
HOME OWNER-BUILDER DECLARATION me
I hereby affirm that I am exempt from the Contractor's License 2a 51 A
Low for the following reason (Section 7031 5, Business and
Professions Code) y Tel No # • • • • • 5
❑ 1, as owner of the property will do the work and the , ) • 2 5 Q 5 0
structure is not intended or offered for sale (Section
7044, Business and Professions Code) • * 25a506
CONSTRUCTION LENDING AGENCY
I hereby affirm that there iso construction lending agency for O 7. 15—, 85
the performance of the work for which this permit is issued
(Sec 3097, Civ C )
Lenders Name �// /r�-�'�'�- �N•a/n�R�� /f+�
Lenore=sAdressl7• L4&Z &A�ICN. 1 d.
I certify that I have read this application and stafe 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 Perminee& - Date-