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HomeMy Public PortalAbout6119 TEMPLE CITY BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION 76A667p R I hereby affirm that I have a' certificate of consent to self C-6 61.7 (2-6e) APPLICATION FOR PLUMBING PERMIT insure,or a certificate of.Workers'Compensation Insurance,or 'I a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING.AND SAFETY Policy No. Company El Certified copy is hereby furnished. FOR APPLICANT TO FI-LL IN (PAINT OR TYPE) FADDRESS Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE department.Date Applicant WATER CLOSETBATHTUB . ..y ,CERTIFICATE'OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE I SHOWER OWNER MAI L (This section need_not be completed if the work involved LAVATORY ADDRESS by the permit is -for 'one hundred dollars ($100) or less.) SINK0 CITY : TEL.NO.. () I certify that in the performance of the.work for which this �~ ermit is issued, I shall not em �I , p ploy any person in any manner DISHWASHER CONTRACTOR - - 0 so as to become subject,to the Workers'Compensation Laws. .I CLOTHES WASHER � ADDRESS ' Date Applicant W SWIMMING POOL RECEPTOR CL NOTICE TO APPLIC.ANT:,If, after making this.Certificate of lk CITY TEL.NO. �Exemption, 'you,'should become 'subject to the•Workers' LAWN SPRINKLER SYSTEMSTATE LIC.Compensation provisions of the Labor Code,.you must forth- i LICENSE NO. CLASS. with comply with such provisions or this permit shall .beWATER HEATER deemed revoked. D TRICT NO. PROCESSED BY GAS SYSTEM OUTLETS Q� LICENSED CONTRACTORS DECLARATION - OUTLETS OVER 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- I FINAL ness and Professions,Code, and my license is in full force and DATE �.- � VALIDATION effect. FINAL / License Number Lic.Class BY Contractor Date ,.❑ I am exempt from the licensing requirements as I am a LAdd. ee licensed architect or ,a registered professional engineerNG PERMIT ISSUING FEE acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE Lic.or Reg.No.. - Date lplicant HOME OWNER-BUILDER DECLARATION I I hereby affirm. that I am exempt from the Contractor's ILicenseLaw for the following reason (Section',7031.5, Bnsi- y TeI..No. mess and Professions.Code): IJU I, as owner of the property, am exclusively contracting with licensed contractors to construct. the project (Section 7044,Business and Professions Code.). R"6 2 1.3 A CONSTRUCTION LENDING AGENCY # o 0 0 0 0.6 ,I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 2 0.0 1 2.50 issued(Sec.3097,Civ.C.). Lender's Name 0. 0 - 12505 Lender's Address 1 () 9. 1 4--82 I certify that I have read this.application and,state that the I above information is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspectio urposes. (( Signature of Permittee Date