HomeMy Public PortalAbout4800 TEMPLE CITY BLVD_Plumbing__ WORKERS'COMPENSATION
herebK m.hatIhcertificate onseto self in- 7A�AM APPLICATION FOR PLUMBING PERMIT
sure,or a caocate of Workers'Compensation Imurance,or a
certified copy thereof(Sac: 3�800, lab C)�8Ver, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Pobc{lby6TDpany 'f�',`/he`_
Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING f
COrtdied copy a filed with the county budding inspection ADDRESS
defwnmarrf . n NUMBER PIXn1RE OR ITEM g FEE ,
APP / EST
Dote �
Applicant WATER CLOSET(TOILET) NEAR
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CERTIFICATE OF EXEMPTfON FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER
to '
(ThIs section need not be completed H the work Involved by MAR
the permit N For one hundred dollars($100)or Mss) UVATO ADDRESS
ADD
I certify that in the performance of the work for which this per- SINK ADD TEL NO
mit is issued, I shall not employ any person in any manner wAVCITY
as to become wblact to the Workers'Compensation Lows D
OR
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT If after mckuq this Certificate of Ex- _ ADDRESS
emption you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR
CITY TEL
ly wit pr.O h pr s of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE * LIC
ed I WATER HEATER LICENSE NO CUSS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROS BY
I hereby off um that 1 am licensed under provisions of Chapter GAS SYSTEM OUTLETS ACCT.t
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Profession Code and my license is in full force and ef- 5 PER SYSTEM FINAL . ID 75.40
fact
HOSE BIB DATE SSC i
License Number�0 �
- Lic Class_ d
ContractorA/�.., lJ�e¢J�P - 0 B"^` TOTAL 75.4000 NECK 75.40
❑ 1 am exempt under Sec _ �.r��.� H
B 8P C for this reason L.1 •�
Plan check fee ►
Date PLUMBING PERMIT ISSUING FEE$ O nsnsrs�� 9/28/95
Signature DI.RR7�1 _
TOTAL FEE D 2W2 1 P1115:19
SINGLE FAMILY l
HOME OWNER-BUILDER DECLARATION Pian check applicant -
I hereby affirm that I am exempt from the Contractor s License Name
Law for the following reason (Section 7031 5, Business and - - -• -
Professions Code) Address
❑ I as owner of the property will do the work and the City Tel No
structure rs not intended or offered for sale(Section 70"
Business and Professions Cade) ►
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 )
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Lender s Name
Lenders Address
I certify that I have read this application and state that the ►
above information is correct I agree to comply with oil County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above menti ed pr party for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature o Permittee Date
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