HomeMy Public PortalAbout6211 TEMPLE CITY BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION •20.0026 DPW 4/90 APPLICATION FOR PLUMBING PERMIT
Ihereby,-off irm.thai(have a certificate of consent to self in- 76A667A
3une,dr a certificate of Workers'Compensation Insurance,or a
' certified copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC'WORKS
Policy No. Company
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) Z � r �
Certified copy is filed with the county building inspection ) DDRESS �.c
A
department. NUMBER FIXTURE OR ITEM @ FEE
Lot_AUTY
WATERCLOSET(TOILET)
Date 0 '� Applicant \ . 'NEAREST Ile
CERTIFICATE OF EXEMPTION FROM WORKERS' 'L 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($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK CITY TEL NO.
mit is issued, I shall not employ any person in any manner so
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER 27
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- _ _ O ,H
em tion,you should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR
P Y I P CITY TEL.NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER.HEATER LICENSE NO. N, CLASS G
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division.3 of'the Business OUTLETS OVER ea7 G'O
and Professions Code, and my license.is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
tett. HOSE BIB DATECli�
- j
License Number !J15Lf�>3_Lic.Class }
IL
y���/ FINAL ry V
Contractor [5 LdJi�Z• Date '� D BY
jC
ACCT. o
I am exempt under Sec. 3303 278.85
B.&P.C. for this reason Plan Check fee r . a
Date: PLUMBING PERMIT ISSUING FEE$ d , i, o —,�- Z
Signature TOTAL FEE �s' TOTAL 2 a �o�'r••_.,
SINGLE FAMILY �1r1ECK 278°45
HOME OWNER-BUILDER DECLARATION Plan check applicant
_ CHANGE .00
I hereby off irm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and
Professions Code): Address 00000-0001 5/30!95
❑ I, as owner of the property, will do the work and the City Tel. No. J7 1 Alij 120
structure is not intended or offered for sale(Section 7044, 06
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
authorize representatives of this County to enter upon the '
above-mentioned proper for inspection.purposes.
_40— 1-t- SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa of Permittee Date
is