HomeMy Public PortalAbout5417 TEMPLE CITY BLVD_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
.! hereby affirm that I have a certificate of consent to self 20-0026 DPW 8/87 C, 1
insure, or a certificate of Workers Compensation Insurance, 76A667A t ILL
or o cerhfted copy thereof (5ec 3800 Lab C) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS '
Policy No Company - I r
Certified copy is hereby furnished
❑ Certified copy is filed with the county building inspet FOR APPLICANT TO FILL IN(PRINT OR TYPE) BDDRE55
non deportment NUMBER FIXTURE OR ITEM ® LOCALITY 'rC.' / /}G' (,/ Oaf G[•l
Date AppliSant WATER CLOSET 14YNEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE - OWNER A 11,4Z e
(This section need not be corepleted IF the work Involved by SHOWER
the pennR Is for one hundred dollars($190)or lass ) LAVATORY / MAIL
I certify that In the performance of the work for which this ADDRESS
permit is issued, I shall not employ any person in any manner SINK CITY TEL NO
so as to become subject to the Workers Compensation Laws _ DISHWASHER ,
CONTRACTOR iq
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If, after making this Certificate of
Exemption, you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Lob-or Code, you must forth CITY NO
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LK
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby offam that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS tO
(commencing with Section 7000) of Division 3 of the Businem OUTLETS OVER
and Professions Code and my hcents is in full force and effect 5 PER SYSTEM FINAL VALIDATION Lyt
License Number Lic Class DATE p
FINAL O
Contractor Date BY fY
O
❑ I am exempt under Sec t
B 8P C for this reasonn
Plan check fee �j'�S`q Z
Dors Z
Signature PLUMBING PERMIT ISSUING FEE S
TOTAL FEE
Plan check applicant c '
SINGLE FAMILY
HOMEOWNER-BUILDER DECLARATION Name ACC�.i
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031 5, Business and ��I 17 4i.41t
'Pr9feesiom Cods) City Tel No , `�
'LP)
1, as owner of the property will do the work and the t� y �TF�_
' structure is not intended or offered for sale (Section ® TOTAL 4u 40
7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY CHE, 4P.Z10'
1 hereby affirm that there is a construction bending agency for C H41GE ,CP 1
the performance of the work for which this permit is Issued
(Sec 3097, Civ C ) '
Larder's Nome
Lender's Address �_7� i M 11:17
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 Stats jaws regulating Plumbing, and hereby
authorize reprelentanves of this County to enter upon Pe
bove-m phoned roperty for inspection purpose y
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa re of Perminee Date -