HomeMy Public PortalAbout5821 TEMPLE CITY BLVD_Plumbing__ WORKER'SCOMP)=NSATION DECLARATION 72D-0026GM87 DPW 9189 APPLICATION FOR PLUMBING PERMIT
78A887A
I "lob affirm-gfat•,,havq,a certificate of,conse.nt to self insure,
or aAartifloise of Wwk"er's Compensation Insu54ncenor a certified
copy thereafisec.3800 Lab.C.) "
COUNTY OF LOS ANGELES DEPT.OF'PUBLIC WORKS' DEPT.OF PUBLIC WORKS DIV.
Policy Nb. Company ;
Certified copy is hereby furnished. ,�/ /�
❑ Certified copy is tiled with the county building inspection FOR APPLICANT TO FILL IN(PRINT OR TYPE) gDDRESS Z f ���//J �/�
department. NUMBER FIXTURE OR ITEM ® FEE
LOCALITY_
Date Applicant WATER CLOSET ' v
NEAREST
CERTIFICATE OF ESS
EXEMPT FROM WORKERS' BATH TUB CROST. GUO /V
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed If the work Involved by the SHOWER MAP BOOK +, PAGE PARCEL
permit is for one hundred dollars($100)or less.) Q LAVATORY 1 OWNER 'M AALTA V
I certify that in the performance of the work for which this permit J �J MAIL /
Is Issued. I shall not employ any person in any manner so as to SINK ADDRESS SVP ` (/IJP ac-01
subject to the Workers'Compensation La
DISWASHER CITY •�a � Cfry TELL..NO.
Date Applicant 9 CLOTHES WASHER CONTRACTOR /(�f � ��r
NOTICE/TO PPLICANT:'If, after makin this Certificate of
Exemption,you should become subject to the Workers'Compensation, SWIMMING POOL RECEPTORy
/ G�
provisions of the Labor Code,you must forthwith comply with such' ADDRESS �lT
7
provisions or this permit shall.be deemed revoked. LAWN SPRINKLER SYSTEM ,
LICENSED CONTRACTORS DECLARATION CITY L�el7q _TEL.NO. . �—� }
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
(commencing with Section 7000)of Division 3 of the Business and STATE LIC..
Professions Code,and,my license Is in full force and effect. 1 11
GAS SYSTEM OUTLETS LICENSE NO., V �� S
OUTLETS OVER DISTRICT NO P SED BY
rl/ 5 PER SYSTEM , O
License Number df LIC.Class
G rLN
Contractor Pt—Y &/��afe Fae a
W
❑ I am exam under Sec. FINAL W
rn. �� BY
B.&P.C.for this reason
Plan check fee_ 1
Date: ► 5
Signature
PLUMBING PERMIT ISSUING FEE$
ACCT.
a
❑ TOTAL FEE �"� �'�
• Plan check applicant
3307 50.51-.1
SINGLE FAMILY • . I i �
HOME OWNER-BUILDER DECLARATION Name
I hereby'affirm that 1 am exempt from the Contractor's License Law I �i L � t=
for the following reason(Section 7031.6, Business and Professions Address
113
Code):
El 1,
Tel.No. CHECK lEvY a 1I)
I,as owner of the property,will do the work and the structure ������ eC�i
Is not Intended or offered for sale(Section 7044, Business
` and Professions Code).
CONSTRUCTION LENDING AGENCY , II Q(�-1 (]� 9/14/911
I,hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, 2875 1 AN 8004
Civ.
C.)
Lend is Name -
Lender\'.Address
I certify that I have read this-application,and state that the above Pol.Inforfnat0n.is correct. I agree to comply with all County ordinances
and State\laws regulating Plumbing', and hereby authorize
representati7.s of this County to enter upon the above-mentioned
property for I spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE