HomeMy Public PortalAbout4947 TEMPLE CITY BLVD_Plumbing__ 1 t ,
�/ reh ,offirm Rat I have
a certificate
DECLARATION APPLICATION FOR PLUMBING PERMIT
i HereBy affvm that I have a certificate of consent to self m ' 7�A�4/� _
sure,or a certificate of Workers Compensation Insurance or a CE 817(REV 8/66) `
certified copy' er f Sec 3800 Lab C ) �
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy Ko Company � �—
Certified copy is hereby furnished❑ FOR APPLICANT TO FILL IN (PRINT OR TYPE)
Certified copy is fled with the county budding inspection ADDRESS
department NUMBER FIXTURE OR ITEM Q FEIF
E
�
.Dote Applicant s/y If . 1
WATER CLOSET(TOILET) NEAREST
2-1 7V
l CERTIFICATE F EXEMPTION FROM WORKERS' BATH TUB CROSS ST I L '
COMPENSATION INSURANCE SHOWER OWNER . T e
(This section(teed not be completed II the work Involved by MAIL � _
the permit is for one hundred dollars($100)or less ) LAVATORY ADDRESS-24 0 1
I certify that in the performance of the work for which this per SINK mit a issued I shall not employ any person In any manner so CITY S TEL NOW r}, ;7
as to become subject the Workers Compensation DISHWASHER CONTRACTOR
Date Appl¢ont - G✓�L CLOTHES WASHER
NOTICE TO APPLICANT If, after making this Certificate of x ADDRESS
empaon you should become subject to the Workers Com n SWIMMING POOL RECEPTOR
CITY TEL NO Q •j/2
lyscificin
with
provisions om of the Labor Code, you moat forthwith comp LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok � STATE LIC
ed / WATER HEATER LICENSE NO CLAS$
LICENSED CONTRACTORS DECLARATION ' DISTRICT NO PROCESSED BY
I hereby off irm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS .5— O
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER J `
and Professions Cade and my license is in full force and ef- 3 PER SYSTEM FINAL/y VALI ATION
fart DATE [— p
License Number6�Lm Class FI R/ C
Contractor Date C
F
am exempt under 56c W
B 8P C for this reasonPlan check fee ► 2
Date PLUMBING PERMIT ISSUING FEE S
Signature /
f
SINGLE FAMILY TOTAL FEE
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor s License Name
Low for the fallowing reason (Section 7031 5 Business and
Professions Code) Address
as owner of the property, will do the work and the City Tel No 5
structure is not intended or offered for sole(Section 7044 A4CT a
Business and Professions Code) •�
CONSTRUCTION LENDING AGENCY - , M7 IU.50
l hereby affirm that there Is a construction lending agency for 1 ITEMS
the performance of the work for which this permit Is Issued ,
(Sea 3097 CI„ C ) TOTAL 112.50
Lender's Name CHECK 112.50 112.f5f�0
( �
J IZ
Lender s Address t ,
I certify that I have read this application and state that the
above Information Is correct I agree to comply with all County 1/2J/89
ordinances and State laws regulating Plumbing and hereby
authorize representatives of this County to enter upon the 07?3 1 AM10:50
above mentioned property for Inspection purposes ,
& /is '� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date