HomeMy Public PortalAbout5011 TEMPLE CITY BLVD_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I�herehy�offirm that I have o certificate of consent to soli 20-0028 DPW 6/e7
'msurs or a certificate of Workers Compensation Insurance 76AS67A ,
or a certified copy thereof (Sec 38110 Lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
.or
No Company '
Certified copy is hereby furnished
Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUA
tion department NUMBER- FIXTURE OR ITEM ® FEE -/
�� LOCALITY
Date ApphSant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS I BATH TUB O a CROSS ST {�
COMPENSATION INSURANCE I OWNER Y \ MAV P'L
'(This section nand not be completed N the work involved by SHOWER +
the permit Is for one hundred dollars($100)or less) I LAVATORY uMAIL
' `+ 4/J t,
s
I certify that d the performance of the work for which this SINK - CITY ' ` TEL NO
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permit is issued, I shall not employ any person in any manner
so as to become jubjeci to the WorkAs Compensation ws DISHWASHER '
CONTRACTOR
Dote plic I CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If, after mak ng thisw4ficatrof ,
Exemption you should become subject to he Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forthCITY TEL NO
with comply with such provisions or this permit shall SPRINKLER SYSTEM shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO CLASS '
LICENSED CONTRACTORS DECLARATION ,f�STRICT BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS <LO
(commencing with Section 7OD0) of Division 3 of the Business OUTLETS OVER
and Professiorn Code and my license is In full force and effect 5 PER SYSTEM FINAe VALIDATION (�
License Number L¢ ClassDA W '
FIN
Contractor Dais BY K
O
I am exempt under Sec U
B 8P C for this reason 0.1
Plan check fee
Dare Z
PLUMBING PERMIT ISSUING FEE S
Signature
TOTAL FEE
Pion check applicant .r ,
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name 3W 34.50
1 hereby affirm tliat I am exempt from the Contractor s License Address 1 ITEtlS
Law for the following reason (Section 7031 5 Business and - `
Professions Code) city Tel No TOTAL 34.50
1, as owner of the property, will do the work and the GECK 34.50
structure is not intended or offered for sale (Section �, 1rllllT� aW
7044, Business and Professions Code) -
CONSTRUCTION LENDING AGENCY '
I hereby affirm that there iso construction lending agency for
the performance of the work for which this permit is issued - DMX601 7/Wi9
(Sec 3097, Civ C )
4438 1 AM 9121
Lenders Name
Lender's Address
I certify that I have read this application and state that the P1111.above information is correct I agree to comply with all County
ordinances and State lows regulating Plumbing, and hereby
authorize repre;entatwes of this County to enter upon the
ve-mentioned property for spection pur osas
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature of Pe 011
tee Date