HomeMy Public PortalAbout5504 TEMPLE CITY BLVD_Plumbing__ WORKER S ODMPENSA]ION DECLARATION 20-OM DPW 6/89 '
I her firm r)tat I haves certificate of consent to ..If m.ure 'a"�'A APPLICATION FOR PLUMBING PERMIT - ll
or a scale of Worker s Compensation Insurance or a certified
copy thereof(Sac 3600 Lob C) t 1 `f
' f, COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
Polley No Company
❑ Certified copy Is hereby furnished
FOR APPLICANT TO FlLL IN(PRINT OR TYPE) BUILDING r/
❑ Certified copy is flies with the county Widmp rcmPemwn ADDRESS I
department NUMBER FIXTURE OR ITEM ® FEE LOCALITY ropw/
Date Applicant / WATER CLOSET NEAREST Aq, or
CERTIFICATE OF EXEMPTION FROM WORKERSCROSS ST
COMPENSATION INSURANCE BATH TUB ASSESSOR�K
(This section need not be completed ti the work Involved by the SHOWER O SO O PAOE00 PARCEL 01
permit Is for one hmrdred dollars($IGO)of lees) LAVATORY U OWNER S
I certify that In the performance of the work for which this permit OWN r
Is Issued I .hall not employ any person In any manner so as to SINK ADORES, L� D
become Subject to the Workers Compensation Lave .�/J
DISWASHER CIT * TEL NO Mtzn
Data Applicant `
CLOTHES WASHER CONTRACT
NOTICE TO APPLICANT a after tothe rker C ompeate of
OA
Exempiron you ehoud become aub)ect[o the Workers ComPeneaton SWIMMING POOL RECEPTOR
provisions of the Labor Code you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CRY TEL NO Y
I hereby affirm that I am licensed under provisions of Chapter B WATER HEATER d
(commencing with Section 7000)of Division 3 of the Business and / STAB
ProleasKons Cade and my license Is in full force and effect GAS SYSTEM OUTLETS LICENSE NO CLASS 0
OUTLETS OVER DISTRICT NO PROCESSED BY Q
e PER SYSTEM
License Number Uc Class
Contractor Dale TNgLE 2�— 7 —V2-- VALIDATION d
rn
❑ I snI exempt under Sac _ ! FINAL 2
B 6P C for this reason
J Q BY
Date Plan check fee
Signature PLUMBING PERMIT ISSUING FEE$ ,
❑ TOTAL FEE S� AI CT.AT `
SINGLE FAMILY Phan cheCk applicant 3307 65.5(1
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I em exempt from the Contractors License Lew 1 ITEhISL
forthefollowing reason (Section 7031 5 Business and Profesalons Address - TOTAL V5 0
-
I as owner of the property will do MGty Tal No e work and the structure CF�CK 65.93
Is not intended or offered for Sale(Section 7044 Business
and Proteealons Code) I , C+* •GI
CONSTRUCTION LENDING AGENCY I
I hereby affirm that there is a construction lending agency for the 0000—OM1 9/20/90
performance of the work for which this permit K. Issued (Sec 3087
Civ C) 2955 i AM 8:39
Lender a Name
Larder a Address
I certify that I have read this application and state that the above - ►
r Information is correct I agree to comply wnh ell County ordinances
and Slate laws regulating Plumbing and hereby authorize
representatives of this County to enter upon the above mentioned r
p for inspection p posse SEE REVERSE FOR EXPLANATORY LANGUAGE
rCia 90090/90