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Home My Public Portal About6029-6031 TEMPLE CITY BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that 1 have a certificate of consent to self 76A667A insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof(Sec.-3880,A-Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. - Company Certified copy is.hereby furnished. Certified co is.filed with the co FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING d PY • y building insp - ADDRESS 0 oZ. '��' G!!1'.At eit tion department. NUMBER FIXTURE.OR ITEM / +�,,� (� 'FEE LOCALITY � � Date "Z fo v A Ii ant WATER CLOSET . PP 4 � NEAREST 1 CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB .� CROSS ST. COMPENSATION INSURANCE OWNER rte' ' l (This.section.need not be completed if the work involved by SHOWER �: -. G' the permit is for one hundred dollars($100)or less.) LAVATORY MAIL �, � ADDRESS 0. �j x I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY •� C y TEL.NO.2�x6_2WA so as to become subject to the Workers'Compensation Laws. 121 DISHWASHER CONTRACTOR ��f✓A 1�+5 .� Date. Applicant CLOTHES.WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers SWIMMING POOL RECEPTOR 'Compensation provisions of the Labor Code, you must forth- CIN,4�//PTrl-`d TEL.NO' LAWN SPRINKLER SYSTEM' _ with comply with such ,provisions or this permit shall be STATE c, LIC. deemed revoked. . WATER HEATER LICENSE NO, - ' 7 CLASS Of =� LICENSED CONTRACTORS DECLARATION DISTRICT N.4 PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000)of Division.3 of the.Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL u VALIDATION C License'Number L J� Lic. Class a DATE gr�-' L6� FINA C Contractor NV'"-~ Date r BY ❑ 1�1 I am exempt under See. H BAP.C. for this-reason - Plan check fee ► ' Date: Signature PLUMBING PERMIT ISSUING FEE$ Tod - TOTAL FEE r1:1 .7 1 P, Plan check-applicant L n u v..0 SINGLE FAMILY ' HOME OWNER-BUILDER DECLARATION Name I hereby affirm that.I am exempt from'the Contractor's License \' Law for the following reason (Section 7031.5, Business and Address % 1 Professions Code): City Tel.-No. , ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale .(Section , 7044; Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C'.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby autho' representatives of this County to enter upon the ab menti d,prop t or inspection purposes. SEE REVERSE FOR.EXPLANATORY LANGUAGE y, Signature of Permittee Date WORKER$;COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A - insure, or a certificate of Workers'Compensation Insuronce; CE B1.7(REV. 10/81) or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY J Policy No. Company Certified copy is hereby furnished.❑ BUILDING �1 FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS (jt Q,� - A C 12 i Certified copy-is filed with the counLy build' g inspec- tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY �,,x LL Date � 4`190Appli4ant• ~do WATER CLOSET 2WI NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. , COMPENSATION INSURANCEi SHOWER , ,� OWNER �',q.C_ V (This section need not be completed if the work Involved by. the permit is for one hundred dollars($100)or less.) MAIL LAVATORY ADDRESS �17rX I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner �� SINK --,,.CITY /! TEL.NO.,24G-2rf f so as to become subject to the Workers'Compensation Laws. DISHWASHER A �•l CONTRACTOR Ol�f✓r0S 4�5. - Date Applicant CLOTHES WASHER �' ADDRESS ,� / ��w NOTICE TO APPLICANT: If, after making this Certificate of W, �L q _ A 1^J Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR �_ , CITY TEL:NO. Compensation provisions of the Labor Code, you must forth- i• LAWN SPRINKLER SYSTEM _ with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. �.� / CLASS JA LICENSED CONTRACTORS DECLARATIONv DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 I GAS SYSTEM UTLETS ..� (commencing with Section 7000)of Division 3 of the Business OUTLETS OVEkT and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL C_ DATE 7eVALIDATION License Number �3 Lic. Class LL c VBY IN O Contractor �/��°'r Date y ❑ I am exempt under Sec. ' ��7 7 � B.BP.C. for this reason /pt� Plan check fee jl�_ i�� Date: Signature PLUMBING PERMIT ISSUING FEE$ Q ' TOTAL FEE SINGLE FAMILY I' Plan check applicant - r HOME OWNER-BUILDER DECLARATION Name , I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the structure is not intended or offered-for sale (Section 7044, Business and Professions Code). , tj CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby author! repr sentatives of this County to enter upon the ab o enti d prXpyr inspection purposes. N SEE REVERSE FOR EXPLANATORY LANGUAGE yri. C %Tgnature of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof(Sec.-38r@0,1Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. _ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ` �� nC✓ Certified copy is filed with the co y building ins ADDRESS Z -A �Grst t 1 fj tion department. NUMBER FIXTURE OR ITEM @ FEE r LOCALITY 27 K � /r l P-yDate �L Applicant 1�+ WATER CLOSET - NEAREST a CERTIFICATE OF EXEMPTION FROM WORKERS' L BATH TUB _ CROSS ST. COMPENSATION INSURANCE OWNER L� (This section need not be completed if the work involved by SHOWER the permit is for one hundred dollars $100 or less. MAIL P ( ) I LAVATORY Z< _ ADDRESS O, arJ IC � 78 I certify that in the performance of the work for which this �t ,` permit is issued, I shall not employ any person in any manner SINK CITY /- ,e i•/ TEL. NO. �6_2Op so as to become subject to the Workers Compensation Laws. DISHWASHER t- CONTRACTOR ®tf f✓•n7S �L Date Applicant CLOTHES WASHER NN�� Co. � ^ NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS � N*L i It ct iCN i�{ , Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY 4/J f /P1rL co TEL. NO. with comply with such provisions or this permit shall be STATE (, LIC. a� deemed revoked. ' WATER HEATER LICENSE NO. 1JS- 7 / CLASS LICENSED CONTRACTORS DECLARATION e`- ' DISTRICT Nom. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM YZ^CAOUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER >" and Professions Code,and my license is in full force and effect. 5 PER SYSTEM CL ��/// /�j j ��/ e DATE L — VALIDATION 0 License Number 7Lic. Class �'� Ix �y FINA 0 Contractor vM�` Date L G 0 BY I.- V ElI am exempt under Sec. N B.BP.C. for this reason Z Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name '"1 1 hereby affirm that I am exempt from the Contractor's License Address Low for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. ❑ 1, as owner of the property, will do the work and the structure is not intended or offered for sale (Section , 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the ► above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby autho representatives of this County to enter upon the ab menti ed prop ty or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) - or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ❑ n ,q Certified copy is filed with the county building inspec- ADDRESS nQ /7 Lm p� ✓C tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY LL �iTu Date 26 Applicant ems. WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' Z BATH TUB r CROSS ST. COMPENSATION INSURANCEOWNER JRA/G- 1 (This section need not be completed if the work involved by SHOWER MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY CA ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY �7 0 f^ TEL. NO. �_2 f so as to become subject to the Workers'Compensation Laws. DISHWASHER �'' CONTRACTOR Date Applicant 'Z,-' CLOTHES WASHER ` z' NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS 64 L - R� Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL. NO. t Compensation provisions of the Labor Code, you must forth- TEL. with complywith such provisions or this permit shall be LAWN SPRINKLER SYSTEM P P STATE - LIC. 9 deemed revoked. WATER HEATER LICENSE NO. �.�_ / CLASS LICENSED CONTRACTORS DECLARATIONq ' DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 v GAS SYSTEM UTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVE =`6'— T Z'�t�� and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINALrl fL DATE VALIDATION O License Number S, Lic. Class J FIN O Contractor ? .2 Date }- ❑ V am exempt under Sec. a / of B.&P.C. for this reason ► ( �' �} Z Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ P Signature TOTAL FEE ) SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and v, Professions Code): City Tel. No. \� ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section , 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name t Lender's Address I certify that I have read this application and state that the , above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authori representatives of this County to enter upon the abo enti d prop ty or inspection purposes. v SEE REVERSE FOR EXPLANATORY LANGUAGE nature of Permittee Dare