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Home My Public Portal About6215 TEMPLE CITY BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby, gfftirrrJ Jl�at I have n-a certificate of consent to self i76A667 DPW 4/90 sure.,Or are�, Aficate of Workers'Compensation Insurance,or a 76A66720-0026 certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS-ANGELES DEPT.,OF PUBLIC WORKS Policy No. Company Certified copy.is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ❑ Certified copy is filed with the county building inspection ADDRESS 49::;0;F10 department. NUMBER FIXTURE OR ITEM FEE /f LOCALITY L� Ddte O Applicant r WATER CLOSET(TOILET)Al NEAREST CERTIFICATE OF EXEMPTION.FROM WORKERS' 2i 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($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- i SINK CITY TEL.NO. mit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation,Laws. DISHWASHER CONTRACTOR Date• Applicant CLOTHES WASHER ADDRESSl6o L �� v✓VGA NOTICE TO APPLICANT: if, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY TEL.NO. _ sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS 6i b LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSEb BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETSa�' 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION fect. HOSE BIB• DATE .� License Number 73 Lic. Class -e36 C FINAL Contractor �`'7��(77151 Date — r� BY V ❑ I am exem t under Sec. AC � P �a !-IV��.R tF B.BP.C. for this reason3 278re8Y5 W • Plan check fee ► 3�0•� � y Date: PLUMBING PERMIT ISSUING FEE$ I ITEMS � Signature TOTAL FEE S TOTAL 2 8 m 85 SINGLE FAMILY i��n� HOME OWNER-BUILDER DECLARATION Plan check applicant CHECK '�7�,� � I 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. 00013-0001 5/30/95 structure is not intended or offered for saleSection 7044, I f Business and Professions Code). ( , 0639 jAli1; 0 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signa a%f Permmi tee -Date r