HomeMy Public PortalAbout4509 TEMPLE CITY BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION rsAaatA
1 hereby affirm that I have • certiftcate of consent to•self Caalrlt-eel APPLICATION FOR PLUMBING PERMIT
insure,or a certificate of Workers'Compensation Insurance,or
a certified copy they o (Sec 3800.Lab C)
G 4 IJ /} -Thi W C19($L)A LT`� COUNTY OF LOS ANGELES BUILDING AND SAFETY
/Policy No .�_Company
Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
Certified copy n filed with the county buiV; nect on NUMBER FIXTURE OR ITEM •
FEE ADDRESS 4509 Temple Ci
Blvd.
pleell LOCALITY
NEAREST
Temple Cit CAA . � ' WATER CLOSET rOnApDcenttyLC ate pl F(LES BATH TUB
CROSS ST Lower Azusa Road
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE, SHOWER OWNER Jg co Acceptance Corporation
LAVATORY MAIL }
(This section need not be completed if the work involved ADDRESS 9604 lower Azusa Road (L
by the permit is for one hundred dollars ($I00) or leen) SINK
CITY Temple City, CA TEL No 443-4437 v
I certify that in the performance of the work for which this DISHWASHER
permit u issued, I shall not employ any person in any manner CONTRACTOR Donald F Laughlin Const.
so as to become subject to thS,Workers' Com ansa o Laws CLOTHES WASHER
y�Date10-7-b2 A bcent 1! Q �A- ADDRESS 9631-C Business Center Dr. W
VD —+s"— SWIMMING POOL RECEPTOR d
NOTICE TO APPLICANT If after making this Certificate of CITYRancho Cucamon 8 CATEL NO 980-7414 to
Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE LIC Z
Compensation provisions of the Labor Code, you must forth- WATER HEATER LICENSE NO 326065 CLASS B
with comply with such provisions or this permit shall be
deemed revoked GASSYSTEM OUTLETS It fid DISTRICT NO PRO SS BV
LICENSED CONTRACTORS DECLARATION OUTLETS OVER J L
1 hereby affirm that I am licensed under provisions of Chapter 6 PE R SYSTEM
9 (commencing with Section 7000) of Division 3 of the Bust FINAL VALIDATION
ness and Professions Code, and my license u in full force and DATE /
effect
FINAL
License Number 3aZ 4awc Clan
VST( Cell /.IWCH BV
Contractor Date1 L /
\❑ 1 am exempt from the licensing requirements as I am a Plan check fee �j(p
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE S S� �- y/ y
acting In my profeanonal 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 ;267 ) 9A
License Law for the following reason (Section 7031 5 Bust City Tel No - # • • • e • 5
nese and Professions Code) ,
0 I, as owner of the property, em exclusively contracting 2 7250
with licensed contractors to construct the project
(Section 7044, Business and Profeswons Code) • • • 72505
CONSTRUCTION LENDING AGENCY 1 0 0 7—8 2
I hereby affirm that there u a construction lending agency
for the performance of the work for which this permit is _ _
issued(Sec 3097, iv C)
Lenders NameMaen State Sanwa Bank
Lender's Address 9000 Valley Blvd, Rosemead, Ca. 91770
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
/
Signature of Permittee Date
P e,�E