HomeMy Public PortalAbout5722 A-E TEMPLE CITY BLVD_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
hereby affirm !hat 1-have o certificate of consent to self in 76A667 DPW 4ie7
sure,or o certificate of Workers Compensation lnsuronc8 or a CE 817(REV 8/86)
certified copy thereof (Sec 38W Lab C ) ..
Policy No "s59mp na y kfw�600 S COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN PRINT OR TYPE BUILDING s '
Certified copy is flied with the county building ins pectio ( 1 ADDRESS 57 ZZ Lt y
, department � NUMBER FIXTURE OR ITEM ® FEE
/7y LOCALITY ��
Date • O Applicant WATER CLOSET (TOILET) it
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS /Q BATH TUB CROSS ST a-7�dS l
COMPENSATION INSURANCE SHOWER OWNER 0� G•slJ P,
(This section need nwnr
not be completed IF the work Iolred by /
the permit Is for one hundred dollars($100)or less ) ! rj LAVATORY ADDRESS/s.2 S L11 - 5 p i5�
MAIL
m
I certify that m the performance of the work for which this per SINK CITY 9n Z4'.7TEL NO
cart is issued I shall not employ any person any manner so
as to become subject to the Workers ompen on Laws DISHWASHER / o�, /�/r-A D
/ CONTRACTOR F-rc,1.1 ILI"
1
Date pP icon 5 CLOTHES WASHER ADDRESS I SO
NOTICE TO APPLICANT If after making this Certificate of Ex- SWIMMING POOL RECEPTOR
empion you should become subject to the Workers Compen *0 TEL NO W-91�/ /
sation provisions of the Labor Code you must forthwith coca Cliv 01:p— ] A`67 'TY
Y P LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE � �( LIC
ed WATER HEATER 3250 LICENSE NO 1445 C C'3
I 32
LICENSED CONTRACTORS DECLARATION L11STB1[T�tyO P Y
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM /�j OUTLETS Q Uhl!//((
(Commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
fed Professions Code and my license is in full force and of 5 PER SYSTEM FINAL y.� A ATION d
Li nse Number f •¢S Lic lav -3(P OSS rci 7 DATE 6 O
�Q/��sx�216L Pest. 3, �g FINAL�J9
Confrptf r D2EckscE� Date 7 0 BY !VY(/ O
I am exempt under Sec ' Wox
B 8P C for this reason Plan check fees
Dote- PLUMBING PERMIT ISSUING FEE S ,
5 onoture7,__ yTOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION PP
I hereby affirm that I am exempt from the Contractor s License Name 5
Law for the following reason (Section 7031 5, Business and
Professions Code) Address ACCT.AT ��Lp
❑ 1, as owner of the property will do the work and the City Tel No 3307 508.0[1
structure is not intended or offered for sale(Section 7044 1 ITEtIS
Business and Professions Code)
CONSTRUCTION LENDING AGENCY ► TOTAL 5108.00
I hereby offirm that there is a construction lending agency for CHECK 9R•00
the performance of the work for which this permit is issuea
(Sec 3097, Civ C CK4M .NI
Lender s Name
0000-0001 3/ 7/90
Lender s Address 9373 1 A1110:311
I certify that I have read this application and state that the
above information is correct I agree to comply with all County log.ordinances and State jaws regulating Plumbing, and hereby -
outhor a representanvas of this County to enter upon the
abov
or-
re a for ms c purpose
?gnature of Permnt eof Permnt e
to SEE REVERSE FOR EXPLANATORY LANGUAGE