HomeMy Public PortalAbout6353-6353 1/2 TEMPLE CITY BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION raaavA
I hereby affirm that I have a certificate of consent to self C9 $1742+e1 APPLICATI N FOR .PLUMBING PERMIT
insure or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800 b C) ,/.�-
Soa�g ' ae4&& 1;& 0 COUNTY OF LOS AN ELES BUILDING AND SAFETY
Polic ompen,
Ce copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING 53�S-3y
ADDRESS •1'� I
Certified copy n filed with the county budding inspect NUMBER FIXTURE OR ITEM • FEE
p _ � � WATER CLOSET LOCALITY C
Date Appl,CJ_
nJ , NEAREST
CERTIFICATE EXEMPTION FROM WORKERS' �C)
COMPENSATION
BATH TUB CROSS ST
INSURANCE � SHOWER OWNER _ 4EA
(Thu section need not be completed If the work Involved 7 LAVATORY MAIL y
p ADDRESS QO )id. d
by the permit is for one hundred dotting (11100) m less) SINKCPI (0CITY 1 TEL N - (�j
1 certify that ,n the performance of the work for which this '� DISHWASHER � 2
permit is issued I shall not employ any person ,n any manner CONTRACTO N 0
so as to become subject to the Workers' Compensation Laws CLOTHES WASHER C U
ADORES l
Dat° Applicant SWIMMING POOL RECEPTOR _ W
NOTICE TO APPLICANT If after making this Certificate of CITY TEL NO%0793
_ tl
Exemption, you should become subject , the Workers LAWN SPRINKLER SYSTEM STA E rt LIC L� Z
Compensation provisions of the Labor Code, you must forth WATER HEATER LICENSE NO f CLASS C—�v
with comply with such provisions or this permit shot] be
deemed revoked DISTRICT NO PR ES$ED BY
GAS SYSTEM OUTLETS
LICENSED CONTRACTORS DECLARATION OUTLETS OVER ��)
I hereby affirm that 1 am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Bus, FINA ./
ness and Professions ,
and my license ,s ,n full force and DATE 'r Q ��� VALIDATION
effect
gQ[T513 FINAL �•
L¢ense Numb��e[a[��.il���L.L�� �� Lic Claes q r]( 'l gy
Contrac2f1-(n,L &, Date /��D i(Z'f�
I am exempt from the Incensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ /
acting ,n my professional capacity (Section 7051, Bus 5�.3
loess and Professions Code) TOTAL FEE
L,c or Reg No Date Plan check applicant 77a -
HOMEOWNER-BUILDER DECLARATION Name
I hereby strum that I am exempt from the Contractor's Address
License Law for the following reason (Section 7031 5, Boa, City Tel No ;2 3 0 P_0 A
ness and Profusions Code)
1, as owner of the property, am exclusively contracting • • • • a Jr
with licensed contractors to construct the project
(Section 7044,Bm,ness and Professions Code) 2 • - 7300
CONSTRUCTION LENDING AGENCY • • • 7 3 0 0 5
I hereby affGm that there is a construction lending agency
for the performance of the work for which this permit Is I ) 2-80
issued(Sec 3097,Civ C)
Lender's Name
Lender's Address
I certify that I have read this application and stele that the
above information is 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 impact rpmes
4 //-/,1�v
S,gmture of Permittee to