HomeMy Public PortalAbout4516 TEMPLE CITY BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION 7694674
1 hereby affirm that I have a certificate of consent to self ca.,7,a-.e1 APPLICATION FOR PLUMBING PERMIT
insure,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C) A COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N ikompanY S ra &en 1 r 1.4 Y ds
❑ Certified copy as hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) ADDRESS
ESS 5 r r rJ n1/�
Certified copy n filed with the county budding inspection NUMBER FIXTURE OR ITEM • FEE
department LOCALITY I7
Date WATER CLOSET Applicant NEAREST
CERTIFICATE OF EXEMPTION-FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER
(Thalia(Thaliasection heed not be completed if the work Involved LAVATORY ADDRESS
by the permst s for care hundred doBara ($100) or less) SINK , CITY TEL NO d
I certify that ,n the performance of the work for which this DISHWASHER U
permit as issued, I shall not employ any person in any manner CONTRACTOR O N 0C
so as to become subject to the Workers' Compensation Laws CLOTHES WASHER ADDRESS /as
7 xM �R O
Date Applicant SWIMMING POOL RECEPTOR U
NOTICE TO APPLICANT If, after making that Certificate of CITY TEL NO g1C d
Exemption, you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE ([ O LIC /� y
Compensation provisions of the Labor Code, you must forth WATER HEATER LICENSE NO / C O / 6 CLASS l: z
with comply with such provisions or this permit shall be
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO ROCESBED BY
LICENSED CONTRACTORS DECLARATION
provisions
SOVER
TEM
1 hereby affirm that I am licensed under proviona of Chapter 6 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Bus, FINAL '� �.6`3 VALIDATION
ness and Professions Code and my license ,n full force and DATE
effect
FINAL
License Number Lac Claw BY -dr
Contractor Date
I am exempt from the licensing requvementa as; I em e
` Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
`acting in my professional capacity (Section 7051, Bus
mess and Professions Code) ;5379 1 A
TOTAL FEE
• • • • •
L¢ or Reg No Date Plan chxk applicant 1 5,
HOME OWNER-BUILDER DECLARATION Name 2 • • 1 '6 5 0
I hereby-affirm that I am exempt from the Contractor's Addraa • • • 1 6 5 0 6
License Law for the following reason (Section 7031 5 Bus,- Qty Tel No - 0 7 1 9—8 3
ness and Profas,ons Code)
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(Section 7044, Business and Professions Code) '
CONSTRUCTION LENDING AGENCY `
I hereby affirm that there as a construction lending agency
for the performance of the work for which this permit as
issued(Sec 3097,Civ C)
Lender's Name
Lender's Address '
I certify that 1 have read this application and state that the
above information,s correct I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize repr Ceti of this County to enter upon the
abov enti a pr y for wpection purpo a
S, •tura of Prermittee Date