HomeMy Public PortalAbout6209 TEMPLE CITY BLVD_Plumbing__ WORKERS'CODAPENSATION DECLARATION 20,0026 DPW 4/90 APPLICATION FOR PLUMBING PERMIT
r hereby, affirm that') have'a certificate of consent to self in- 76A667A
sure,Or a certificate of Workers.'Compensation Insurance,or a
certfied copy thereof(Sec. 3800, Lab. C.)
Foltcy No. Company 1 COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN PRINT.OR TYPE
❑ Certified copy.is filed with the county building inspection NUMBER FIXTURE OR ITEM •( ) ADDRESS
department. @ FEE LOCALITY
-�,
Ddte• — b" Applicant WATER CLOSET(TOILET) NEAREST 01
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
(This section need.not be completed If the work Involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK CITY TEL.NO.
mit is issued, I shall not employ any person in any manner so
as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR LJ
C,
Date. Applicant CLOTHES WASHER 'ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY Pk TEL.NO. a
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WAFER HEATER LICENSE NO. r w CLASS C.
LICENSED CONTRACTORS DECLARATION DISTRICT N C CESSEv
I hereby affirm that I am licensed under provisions of Chapter 'GAS SYSTEM OUTLETS n v
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER i !!d
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect. � ib HOSE BIB DATE l�Z� d
�
License Number Lic. Class. IIL
R FINAL V
Contractor /`'i �.�7„ i P/�'Date ` `r_ BY cr -- — cc
❑ I am exempt under Sec. ACC
I A4 V
'B.BP.C. for this reason 27c} O d
Plan check fee �'dt a OL u,,, y
Date: PLUMBING PERMIT ISSUING FEE$ 5` Z ITEMS EMS Z
Signature TOTAL FEE O TOTAL 273. 85
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant CHECK 278.85
1 hereby affirm that I am exempt from the Contractor's License Name CHANGE .00
Law for the following reason (Section 7031.5, Business and
Professions Code): Address
I, as owner of the property, will do the work and the City . Tel. No. 0000-0001 5/30/$5
structure is not intended or offered for sale(Section 7044, 1 AM11a29
Business and Professions Code). 0636,
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
PON-
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-menti ed property for inspection purposes.
0 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature Permittee Date