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Home My Public Portal About4518 TEMPLE CITY BLVD_Plumbing__ ftRK off irm that COMPENSATION have DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 20-0028 DPW 8/87 insure or a certificate of Workers Compensation Insurance 76A887A or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS Policy No Company ' Certified copy is hereby furnished DI ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN(PRINT OR TYPE) BADDRRESS 1/S/O TC�,� � C'y/ tion department NUMBER FIXTURE OR ITEM ® FEE O r.J Date Apph,ant WATER CLOSET HtEST Te CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS St ✓rt2 S4 Te G G� P' COMPENSATION INSURANCE � (This sorflon need not be completed It the work involved by SHOWER OWNER ,4� y�"`�5 . ! o!Z the ptrmlt Is for one hundred dollars(111100)or less ) LAVATORY MAIL 1 certify that in the performome of the work for which this ADDRESS`KJ8 kh.i r V,6111,1 permit is issued 1 shall not employ any person in any manner SINK CIT1'Jy[M TEL NO so as to become subject to the War l n'Compensation Lows DISHWASHER CONTRACTOR r 7ti ,S2fVl CG Dots .9_0oC'_ Arplicant W CLOTHES WASHER ADDRESS pZ LE lr �r NOTICE TO APPLICANT If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption you should become subject Workers,to the Workeyf�'�� Compensation provtstons of the Labor Code, you must forth CITY Pb TEL NO Z$8- g'o,� with comply with such provisions or this LAWN SPRINKLER SYSTEM P Y P permit shall be STATE 8"1 ,/ LIC CL deemed revoked WATER HEATER LICENSE NO �7 / ��7 CI.455 �- LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY I here offmn that I am licensed under GAS SYSTEM OUTLETS b by provisions of Chapter 9 Y (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect 5 PER SYSTEM I FINAL License Number Zi `((?(04 tic Clan C-3 pq>•E ��_3_q VALIDATION U ConHactorAr-Fhsir 1\L OS Dote �- Zo-�� BY I am exempt under Sec B BP C for this reason Plan Check fee Signature ,(,e PLUMBING PERMIT ISSUING FEES G ,S"D Z TOTAL FEE Q Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Nome - I hereby affirm that I am exempt from the Contractor s License 1II_t Law for the following reason (Section 7031 5, Business and Address Professions Code) City Tel No l ll}AL 26 - 20 ❑ I, as owner of the property, will do the work and the CAN 2$,2!L structure is not intended or offered for sale (Section 7044, Business and Professions Code) ' t-RAMIE ,IJIJ 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 s J1[i], 711Gf`11 (Sec 30917, Civ C ) K15 1 AIM:17 Lenders Name Lenders Address ' + I certify that I have read this application and state that the above information is correct I agree to comply with all County ' ordinances and State jaws regulating Plumbing and hereby authorize reprelentatives of this County to enter upon the abov -mentioned prop" for inspection purposes ,O q SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date l APPLICATION FOR PLUMBING PERMIT WORKERS COMPENSATION DECLARATION i7 I hereby offvm that I hove a certificate of consent to self '76A667q L Insure, or a certificate of Workers' Compensation Insurance, CE 817(REV 10/81) ' 111, or a certified .�copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY ' Policy Nofim/ Company • Q• Certified copy is hereby furnished BUILDING ' ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN(PRIM OR TYPE) ADDRESS p t C s V1 s hon department NUMBER FIXTURE OR ITEM ® FEE LOCALITY Dote Appllgant WATER CLOSET "M I `Y CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CRRSS S7 COMPENSATION INSURANCE SHOWER OWNER tos (This section nod not be completed If the work Involved by MAIL the permit is for oo hatsdrod dollars ($100)or los) LAVATORY ADDRESS - I certify that In the performonce of the work for which this permit Is Issued, I shall not employ any person In any manner SINK CITY TEL NO so as to become subject to the Workers'Compensation Laws DISHWASHER Y� coNrwacroR P N S � Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT If after making this Certificate of 1li' t9 Ql N r Exemption, you should become subject to the Workers SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code you must forth- CITY TEL NO 15 LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC deemed revoked WATER HEATER LICENSE NO LIq104f7lCLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY I here off that I am licensed under p GAS SYSTEM OUTLETS by pion 3 of of Chapter 9 / Q > (commencing s Coith Section y license of is in fn 3 of the Buffets 5 PER SYSTEM and Professions Code,and my license Is In lull force and effect 5 PER SYSTEM FINALry d DATE (+ �s VALIDATION v License Number Lic ClassIY FINAL O Contractor Date BY �" C ❑ I am exempt under Sec d N B 8P C for this reason Z Plan check fee Dote i Poo. PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name T 3 7 9,2 A I hereby affirm that I am exempt from the Contractor s License ,address Law for the following reason (Section 7031 5, Business and # • • • ' • 5 Professions Code) City Tel No Z is • 1'650 ❑ 1, as owner of the property, will do the work and the stru44 cture Is not Intended or offered for sale (Section 00o v e ) �,rJ Q LTy 70Business and Professions Code) CONSTRUCTION LENDING AGENCY 07 1 9,-83 1 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 ) Lenders Name Lenders Address - I certify that I have read this application and state that the ► above In(ormahon is correct I agree to comply with all County ordinances and State lows regulating Plumbing and hereby I authonze r esem es of this County to anter upon the a ve m e ne r rty forAspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE S nature of m tee Date '