HomeMy Public PortalAbout4829 TEMPLE CITY BLVD_Plumbing__ Wb9KE9S'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �7
=�,I hereby affirm-that I have a certificate of consent to self 20.0026 DPW 6/87 C I
imum or a certificate of Workers Compensation Insurance, 76AG67A lul
oro certif�ie�d�coopyyth�ereof (Sec 38DO, Lab C ) � � ^ 'COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
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Certified copy is hereby furnished ,AUIO S -v
❑ FOR APPl1CANi TO FILL IN(PRIM OR TYPE) SS
S
Certified copy is filed with the county budding inspec-
tion department % NUMBER FIXTURE OR TEEM HE LOCALITY
WATER CLOSET
Dote Ir AppMPTI NEAREST
CERTIFICATE OF EXEMPTION FROM WOR ERS BATH TUB Q CROSS ST
COMPENSATION INSURANCE OWNER -
(This section need not be s:ompl"R the work Involved by SHOWER
the jsomilt is for ono hundred dollen ($100)or loss ) LAVATORY AZAR
ADDRESS Ok' t0
I certify that m the performance of the souk for which this
permit is issued I shall not employ any person in any manner SINK CITY TEL NO
w as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER1
NOTICE TO APPLICANT If, after making this Certificate of SWIMMING COOL RECEPTOR ADDRESS •�• 17a-1'� �—
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code, you must forth- Cm 1�.Q S.� TEL NO .moo
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE LIC
deemed revoked WATER HEATER LICENSE NO 603 AL. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO BY '
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS O p'
(commencing with Section 700D) of Division 3 of the Business OUTLETS OVER U }}
and Professions Code,and my license is in full force and effect S PER SYSTEM FINAL c qty VALIDATION D:
License Number 402u'&� its Class DATE S-2 // p
T 4aFINAL Q� U�
Contractor `Ete _ BY L
O~
13I am exempt under Sac
B 6P C for this reason Plan check fee
Dots PLUMBING PERMIT ISSUING FEE S
Sig nature
TOTAL FEE r
ACCT.i
Plan check applicant
SINGLE FAMILY 4M7 52.00
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s Liceme Address 1
Law for the following reason (Section 7031 5 Business and
Profouions Code) CityTel No /s_ I OTAL Cu . 00
❑ I, as owner of the property will do the work and the LQ OECK I
structure is not intended or offered for Sale (Section
7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued4/233/90
(Sec 3097 Civ C ) � i
Ail 9:24 .
Lender s Nome
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 lows regulating Plumbing and hereby
authorize reprelentatives of this County to enter upon the
above mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o ermSignature o e/41 V Date