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HomeMy Public PortalAbout4830 TEMPLE CITY BLVD_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby offum that I have a certificate oL consenµq self 7M6yA� Insure u a certificate of Workers' Compbnsatlon lns:rrance a g7q(REV 10181) or o certified copy thereof (Sec 3000 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company Certified copy Is hereby furnished a ( ) BUILDING LI 3 p I r V ❑ FOR APPUG4NT TO FILL IN PRINT OR TYPE r `i Certified copy building with the county bulldiInspec- ADDRESS tion department NUMBER FIXTURE OR ITEM ® FEE Localm 1 C; Date Appligant WATER CLOSET 1 -� NEAREST n_ CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 1 CROSS ST LO It.IZ'L �yZV-S Q COMPENSATION INSURANCE ^ OWNER NiC,U LA.i G ��LI C-fi f L.T (This section need not be completed If the work Insel.ed by SHOWER the permit is for one hundred dollars($100)or less ) LAVAiORVMAIL ADDRESS S4V„A I certify that In the performance of the work for which this 3 Permit is Issued, I stall not employ any person in any manner SINK f _�. CITY TEL NO 2 6^2Q so as to become subject to the Workers Compensation Laws DISHWASHER CONTRACTOR - y/Dote 10 / f Applicant Sa ' 4~r" CLOTHES WASHER ADDRESS NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL REQPTOR Exemption, you should become subject to the Workers' CITY TEL HD Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC deemed revoked WATER HEATER LICENSE NO CUSS LICENSED CONTRACTORS DECLARATION DISTRICT NO' PROCESSED BY I hereby affirm that I am licertsed under provisions of Chapter 9 GAS SYSTEM OUTLETS A (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER s and Professions Code and my license Is in full force and effect S PER SYSTEM FINAL.y �./� 6 DATE / !/7l VALIDATION u License Number Llc Class FINAL O Contractor Dote BY DW 1 am exempt under Sec n. 0 CLP C far this reason Plan check fee Z SlgnSignatureDale PLUMBING PERMIT ISSUING FEE$ TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractors License Address $0 8 0 6 A Law for the following reason (Section 7031 5, Business and Professions Code) Cly Tel No # • • • • • 5 © I as owner of the proWty will do the work and the 1 • • 3 Q.5 0 structure is not intended or offered for sole (Section ► 7044, Business and Professions Code) • • • 3 4.5 0 Fs CONSTRUCTION LENDING AGENCY I hereby offum that there is a construction lending agency fa 1 0 0 1 -8 4 the performance of the work for which this permit Is Issued (Sec 3097 C.v C ) Lender's Nome Lender's Address I certify that I have read this application and state that the Pool 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 pbov mentioned property for inspection purpowa Il�s c,"' 10,11 O/1 SEE REVERSE FOR EXPLANATORY LANGUAGE iSignature of Permittee Date