HomeMy Public PortalAbout5729 TEMPLE CITY BLVD_Plumbing__ St-40-: 1PRKERS'COMPENSATION DECLARATION 7GA667A
I hereby affirm that I have w certificate of consent to self cc 617 (2-90) APPLICATION FOR PLUMBING PERMIT
insure,or a certificate of Workers'Compensation Insurance,or I
a.certified.ropy thereof(Sec.3800,Lab.C.), COUNTY OF LOS ANGELES BUILDINGND SAFETY
Policy No: CompanyIJ"b
I)Cl Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
NUMBER FIXTURE OR ITEM • FEE ADDRESS
Certified copy is filed with the county building inspection.
department. WATER CLOSET LOCALITY
Date - Applicant NEAREST
BATH TUB CROSS S.T.
CERTIFICATE OF EXEMPTION FROM WORKERS.'
COMPENSATION INSURANCE SHOWER OWNER
H MAI L
(TMS section need not be completed N the work involved LAVATORY / ADDRESS
by the pdmit is for one hundred dollars ($100) or less.). SINK 0
CITY .� TEL.NO�$6 1t C�
I certify that in the performance of the work for which this DISHWASHER
permit is issued,'I shall not employ prso in any anne CONTRACTOR ! •O
so as tQo become subject to the W rk o ensat' La CLOTHES WASHER
Date _ ADDRESS / � U
Applicant W
SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT: If •fter makin this Certificate of CITY TEL.NO.;IJ N
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM
STATE LIC. 7/
Compensation provisions of the Labor Code,you must forth- Z 3 �-�
with comply with such provisions or this permit shall be
WATER HEATER LICENSE'NO. J j 5(� CLASS'
,deemed revoked. GAS SYSTEM OUTLETS / DISTRICT NNO'. P CESSE.D BY
LI.CENSED CONTRACTORS DECLARATION OUTLETS OVER C� 4
I hereby affirm that I,am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the'Busi-. FINAL
nese.and Professions Code,and my license is in full force and DATE - " VALI'DATION
effect.
361601 �-36 FINAL,
License Number Lic.ClassBY
Contracto W Date
1 am exempt from the licensing requirements as I am a [:Name
napplicant
'U' �
licensed architect or a registered professional engineerUING.FEE$ r
acting in my professional capacity (Section 705.1, Bus-
iness and Professions Code). TOTAL FEE
Lic,or Reg.No. Date
HOME OWNER-BUILDER DECLARATION t
I hereby affirm that iam exempt from the .Contractor', Address ,
License Law for the:following reason (Section.7031.5, Busi- Cit), TeL No.
ness and Professions Code):
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
.(Section 7044,Business and Professions Code).
' -
CONSTRUCTION LENDING AGENCY �22G3A`�
I hereby affirm that there is a construction lending agency # 0,0 0 0 0 5
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). 2 0 1 36600
Lender's Name
0913600:
Lender's Address
I certify that I'have readthis application and.state that the 09,24-80
above information is correct.I agree to comply with all County SEE REVERSE FOR.EXPLANATORY LANGUAGE
ordinances and State laws regulating.Plumbing; and hereby
authoriz repr sentatives of this County to enter upon the
above e i ed operty for' ectI purposes.
ignature offermittee Date '