HomeMy Public PortalAbout4510 TEMPLE CITY BLVD_Plumbing__ WORKERS'COMPENSATION cafeDECLARAT40N
corse APPLICATION FOR PLUMBING PERMIT
I hereby affum that I have a certificate of consent to self 70.46G7A
insure w o certificate of Workers Compensation Insurance, CE 817(REV 10/81)
or q�e_stifyed copy thereof (Sec 3800 Lab C ) r COUNTY OF LOS ANGELES BUILDING AND SAFETY
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PolicyNo
_TOCA1 Company
Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDIt{G
nded a copy fled with the county budding m
bospec- ADDRESS .r
hon,department—rtFIXTUREnt NUMBER FIXTURE OR ITEM ® FEE
poteApphSant WATER CLOSET LOCALITY
NEAREST
CERTIFICATE OF EXEMPTION FIR&WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE
SHOWEROWNER
(This section need not be completeH M
d e Mork Involved by —
the permit is for one hundred dollars($100)or less ) LAVATORY A0MAIL
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certify that m the performance of the work fat which this
42,
permit is Issued,I shall not employ any person in any manner SINK , CITY TEL NO �4a
so as to become subject to the Workers'Compensation Laws
/ DISHWASHER - — CONTRACTOR fjj!VL!l NAB
Date Applicant CLOTHES WASHER � ADDRESS
NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR
Exemption you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM Cfry TEL NO G�y�
with comply with such provisions or this permit shall be STATECJr dc LIC '
deemed revoked WATER HEATER LICENSE NO 3 OG S CLASS ..
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affum that I am licensed under provlslons of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER Y
and Professions Code and my license Is in full force and effect 5 PER SYSTEM FINAL // VALIDATION 0
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License Number. 3 Zro 04 1DATE' Uc Class 13—� m
FINAL O
Contractor Date BY
❑ W
am exempt under Sec un
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B 8P C for this reason Plan check fee Z
Dat
PLUMBING PERMIT ISSUING FEES Q
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant '$9 3.5 0 A
HOME OWNER-BUILDER DECLARATION Nome
I hereby affirm that I am exempt from the Contractor s License Address �� •,• • 5
Law for the following reason (Section 7031 5 Business and
Professions Code) t
13 City Tel No 2 i •
I as owner of the property, will do the work and the 8 s 5 Q
•}• 8 a 5 Qv
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structure is not Intended or offered for sale (Section , I i
70 , Business and Professions Code) 0 L25-83
CONSTRUCTION LENDING AGENCY
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 Nome
Lander s AM. dress
I certify that I have read this application and state that the Pilo
Information Is correct I agree to comply with all County
ordinances and State lows regulating Plumbing and hereby
authorize representatives of this County to enter upon the
olio memloned pro rty for ms{>echon purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signalure of Permitfee Date