HomeMy Public PortalAbout6351 TEMPLE CITY BLVD_Plumbing__ WORKERS'COI have aCieT[ONDECLARATION >swsa>w APPLICATION FOR PLUMBING PERMIT
1 hereby affirm that have certificate of consent to self csi> Is-eel
insure, or a cernhcate of Workers'
rs'Companaahon Insurance,or
a certified copy thereof(Sec 3800,Lab C)
(�� COUNTY OF LOS ANG LES BUILDING AND SAFETY
Poll* 170�`f�p Company
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I ' CeWfied copy Is hereby faro shad FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING (Z(
rU�y/CeNUMBER FIXTURE OR ITEM • FEE ADDRESS J ` 1�✓
Certified copy Is filed with the county building impact
� WATER CLOSET
Det M Appl nlFt t NEAREST
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CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER �s
MAIL �s �
(This section need not be completed If the work Involved LAVATORY ADDRESS &)SO -SA.-601b e� �
by the permit is for one hundred dollar ($10(1) or less) SINK cITY� TEL N�b'rO I'// U
I certify that in the performance of the work for which this DISHWASHER U
permit is Issued, I shall not employ any person in any manner CONTRACTO U
so as to become subject to the Workers' Compensation Laws CLOTHES WASHER U
ADDRE93
LU Date Applicant SWIMMING POOL RECEPTOR d
NOTICE TO APPLICANT If, after making this Certificate of CITYCr
F TEL N _97 of
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC Q Z
Compensation provisions of the Labor Code, you must forth LICENSE NO 3 CLASS i>
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked GAS SYSTEM OUTLETS l3 DISTRICT NO P OCESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER S elr/
1 hereby affirm that I am licensed under provisions of Chapter B PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Bust FINAL/f �,.r r S7 VALIDATION
news and Professions Code, and my license is in full force and DATE "� 7 ci
effect �2
��r FINAL
License b '3 3 L¢ Clam C-- FI
Contractor Date
F1 I am exempt from the licensing requirements as I am a Plan Check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEES
acting in my professional capacity (Section 7051, Bus
mess and Professions Code) TOTAL FEE a
Lie or Reg No Date Plan check applicant
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section 7031 5, Busi City Tel No
rico and Professions Code)
1, as owner of the property, am exclusively contracting :13 04 9 A
with licensed contractors to construct the project
(Section 7044, Business and Professions Code) — ----- # • e e • • Jr
CONSTRUCTION LENDING AGENCY 2 . 0 4 2 0 0
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is • • • 42006
issued(Sec 3097 Civ C)
Lender's Name 11. 12-80
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State lawn regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above mentioned property for inspection purposes
- a - d
Signature of Permittee Date