HomeMy Public PortalAbout5728 A-E TEMPLE CITY BLVD_Plumbing__ WORKERS COMPENSATIONDECLARATIONAPPLICATION FOR PLUMBING PERMIT
I hereby affirm that 1 hays a certificate of content to self m 76466e DPW u®
sure,or a certificate of workers Compensation Insurance or a
764667A
sure, 8i8E
certified copy thereof iSec 3800 Lab C ) ( )
Policy NoW C$'L'SS�aSpY COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN (PRIM OR TYRE) BUILDING
�Cemfied copy m filedPP
ith the county building inspection
department NUMBER FIXTURE -7
ADDRESS /
URE OR ITEM ® FEE LOCALIT
l icon S WATER CLOSET(TOILET) 50 NEAREST
' r..710-
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST s U
COMPENSATION INSURANCE SHOWER OWNER fs.�.r Gp,Jle
(This section need not be wmplefed H the work Involved by �y
the permit Is for one hundred dollars ($100)or Ins) LAVATORY ADDRESS 5
I certify that in the performance of the work for which this per �.`
mit is issued, I shall not employ any person in any manner so SINK CITY �.` 1�i47 TEL NO
as to become subject to the Workers Compensation Laws CR,•
DISHWASHER /� COMRACTOR b� �(�S`LC
Date Applicant S CLOTHES WASHER 0 ADDRESSS
NOTICE TO APPLICANT If after making this Certificate of Ex-
emption you should become subject to the Workers Camper- CITY a?it,,-.,. '7174-0 TEL NO jff-s1�
sation provisions of the Labor Code you must forthwith comp-
ly LAWN with such provisions or this permit shall be deemed revok- STATE A LI
LICENSED CONTRACTORS DECLARATION C /+
ed WATER HEATER LICENSE NO 14.45 CLA55 ` "3""
O DI�TRK Npi BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM 5 OUTLETS `Q/,( !!y
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and of 5 PER SYSTEM FINAL �/' L►a A TION S
S 31 DATE !!
U
L cense Number � � Li Class ` a� FINAL J / O
f�L �REWSLb�L � r 7 `rd BY o
on acro
r
❑ I am exempt under Sec W
B 8P C for this reason Plan Check fee ►
C D J
PLUMBING PERMIT ISSUING FEE $
Signature
� TOTAL FEE
SINGLE FAMILY Plan 6mnf
HOME OWNon check a
ER-BUILDER DECLARATION pp -
I hereby affirm that I am exempt from the Contractor s License Name `
Law for the following reason (Section 7031 5 Business and ACCTrAv
Professions Code) Address
3,307 50°.00
I as owner of the property, will do the work and the City Tel No i
structure is not intended or offered for sale(Section 7044 1 ITEMS
Business and Professions Code) TOTAL- 508 . 011)
CONSTRUCTION LENDING AGENCY C oECK 508.0[1
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued C r00
(Sec 3097 Civ C )
Lender s Name 0000-0001 3/ 7/90
Lender s Address 9372 1 AM10"30
1 certify that I have read this application and state that the -
above information is correct I agree to comply with oil County
ordinances and State laws regulating Plumbing and hereby - 11
authorize representatives of this County to enter upo/,'?
e
oboe enhone o for ins purposes '
3 7a SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee - Date r