HomeMy Public PortalAbout5466 TEMPLE CITY BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby offemylhat I have a certificate of content to self In 7�A�4/87
sure or a eertdlcate of Workers Compensation Insurance or a CE Bl7(REV 8/86)
Policy N copy thereof (Sec 3800 Lob C�
Policy No Company. + COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county budding Inspection ADDRESSJ6 6
department \ NUMBER FIXTURE OR ITEM @ FEE LOCALITY p
Dote Appllcont WATER CLOSET TOILET) D NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS
BATH TUB` CROSS Si
COMPENSATION INSURANCE _ SHOWER OWNER
(ibis iechonee
need not he completed If tho work Involved by MAIL
the permit is for one hundred dollars({100)or bn) LAVATORY ADDRESS
I certify that in the performance of the work for which this per BINK CITU TEL NO
mit is Issued I shall not employ any person in any monner so
as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR
Date Apphcant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT If after making this Certificate of Ex- SWIMMING Ia00L RECEPTOR
emption you should become subject to the Workers Compen CITY TEL NO
sahon provisions of the Labor Code you must forthwith comp LAWN SPRINKLER SYSTEM
Ilywith such provisions or this permit shall be deemed revok STATE /� ''E UC
WATER HEATER LICENSE NO T V CLASS
LICENSED CONTRACTORS DECLARATION - DISTRICT NO OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM 2�OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION >'
fect DATE d
` O
J
License Number ?a�—LIC.Class _ - U
r /T✓Cil FINALIZ
Contra<tor�jl�%�`��Date L !! C/ BY O
H
1 am exempt under Sec V
/ W
B 8P C for this reason Plan check fee
DOt° PLUMBING PERMIT ISSUING FEE$ O
Signature
TOTAL FEE s
SINGLE FAMILY `
HOME OWNER BUILDER DECLARATION Plan check applicant r}
1 hereby affirm that I am exempt from the Contractor s License Name ACCT•a x
Law for the following reason (Section 7031 5 Business and 4;•�,
Profeuions Code) Address 3307
❑ 'I, as owner of the property will do the work and the City Tel No 1 ITEMS
structure Is not intended or offered for sale(Section 7044 TOTAL ' s _Qd
Business and Professions Code) ,
CONSTRUCTION LENDING AGENCY - ► C�'IEGK 43.OU
1 hereby affirm that there Is a construction lending agency for L � •(�
the performance of the work for which this permit is Issued
(Sec 3097, Civ C )
F L
Lender s Name nrtvWnnn I WOW 1 2/15/9Z1
Lender s Address 8961E 1 AM 9:41
1 certify that I have ieod this application and state that the
above information a correct I ogres to comply with all County ► ,
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the '
obo mentor rty for Inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sigrtfture of Permittee Date