HomeMy Public PortalAbout6349 TEMPLE CITY BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION reasvA
I hereby affirm that I have a certificate of consent to self O9817 (Z-11e) APPLICATION FOR PLUMBING PERMIT r�'LJII
insure,or a certiFldete of Workers'Compensation Insurance or
a ce i d copy thereof(Sec 38 b C)
py7 COUNTY OF LOS NGELES �/� BUILDING AND SAFETY
Po cy o � ^I vCompim dx
1 I Cgrt'ned copy u hereby fu a FOR APPLICANT TO FILL IN (PRINT OR TYPE) B LDING (�
LIr�Oy/ NUMBER FIXTURE OR rTEM • FEE ADDRESS I
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Certified copy o fled with the county building inspection
de LOCALI
WATER CLOSET
Date NEAREST
BATH TUB 3 CROSSST LyVIrLN
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER 1J CC
MAIL
(This section need not be completed If the work involved LAVATORY ADDRESS nov
by the permit is; for one hundred dollars ($100) or leas) SINK CITY' TEL NO O
I certify that in the performance of the work for which this DISHWASHER 3 CONTRACTO - U
permit is Issued, I shall not employ any person In any manner
so as to become subject to the Workers' Compensation Laws CLOTHES WASHER ADDRESSM 3
26 FLMUiAto
Date Applicant SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT If, after making this Certificate of CIT TEL NO ILW
Exemption, you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE LIC t/3
Compensation provisions of the Labor Code, you must forth LICENSE NO CLASS Q3 6 ?
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked GAS SYSTEM OUTLETS 3 DISTRICT�N/9 PR CEDED B
LICENSED CONTRACTORS DECLARATION OUTLETS OVER Si�C
1 hereby affirm that I am licensed under provisions of Chapter S PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Bus, FINAL VALIDATION
nese and Professions Code, and my license Is ,n full force and DATE �' �Q f
effect Q /� e7 L
icense Numb. 1 a Lrc Class e^- `3 ire BANAL
�{,J
ntractor A'ss Date tr^lel"6 Q .
I am exempt from the licensing requirements as I em a Plan Check fee
-
1,censed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus Ss3
mess and Professions Code) TOTAL FEE
Lrc or Reg No Date Plan check applicant
HOMEOWNER-BUILDERDECLARATION Name
I hereby affnm that 1 am exempt from the Contractor's Address
License Law for the following reason (Section 7031 5, Buse IC,rV Tel No
neat and Profeasions Code) E3 0 1 8 A
I, as owner of the property, em exclusively contracting
with licensed contractors to construct the project # • • • • • 5
(Section 7044,Business and Professions Code)
2 • • 4200
CONSTRUCTION LENDING AGENCY
I hereby affnm that there is a construction lending agency • • • 4 2 005
for the performance of the work for which this permit is
issued(Sec 3097,Civ C) 1 1 1 2-80
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the
above information u 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 inspect urposes
11- lid-4m
Signature of Permittee I Date