HomeMy Public PortalAbout5629-1/2-5631-5631 1/2 TEMPLE CITY BLVD_Plumbing__ :her Iaffym th COMPENSATION DECLARATIONconte APPLICATION FOR PLUMBING PERMIT
I hereby offArm fhatJ have a cenifmote of consent to self 70A667A
insure, or a certificate of Workers'Compensation Insurance, CE 817(REV 10/81)
or a certified copy thereof (Sec 3800 lob C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished BUILDING y
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS lY
Certified copy is filed with the county budding inspec-
hondepartmenl NUMBER FIXTURE OR ITEM ® FEE �Ndr
LOCALITY
Date AppllSant WATER CLOSET NEAREST /
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST A+ 614F
COMPENSATION INSURANCE
(This section need not be campls,ts,d If the work InvelwOWNER rd by SHOWER Y//.04/ m eo
j the permit Is for oris,hundred dollars ($100)or lass) LAVATORY D IL 05 F� �o /j
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY -5-AW � FL TEL NOoz G
so m to become subject to the Workers'Compensation Laws
DISHWASHER CONTRACTOR
Dote 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 Labor Code, you must forth LAWN SPRINKLER SYSTEM CRY ATEL NO
with comply with such provisions or this permit shall be STATE LK
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DESTRUCT,1{Q BY
I hereby offvm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS D IC7 JY(
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER f Y
and Professions Code and my license is in full force and effect 5 PER YSTEM FINALVALIDION
6.
d �
License Number Lic Clms DATE m
FINAL O
Contractor Date BY t~.!
W
1 am exempt under Sec H
B 8P C for this reason Z
Plan check fee
Dote PLUMBING PERMIT ISSUING FEE f 0
Signature
TOTAL FEE _ s 1 4 a A A
Plan check applicant
SINGLE FAMILY # • • • • • rj
HOME OWNER BUILDER DECLARATION Nome
I hereby affirm that I am exempt from the Contractor's License Address ( • • 1 650
Low for the following reason (Section 7031 5, Business and
Pro ions Code) City Tel No • • e 1 6 5 0 0
I as owner of the property will do the work and the ►
structure is not intended or offered for sale (Section U 1.24-85
704E Business and Professions Code)
CONSTRUCTION LENDING AGENCY r
I hereby off rm that there is a construction lending agency for
the performance of the work for which this Permit is issued
(Sec 3097,Gv C ) ,
Lender s Name
Lender s Address
I certify that I have read this application and trate that the r ►
above mformation is correct I agree to comply with all County
ordinances and State laws regulating Plumbing and hereby
outhonza represem es of this County to-enter upon the
0 ov s Ported arty for inspection purposes
f i / SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permit!e Date