HomeMy Public PortalAbout6355 TEMPLE CITY BLVD_Plumbing__ WQRKERS'COMPENSATION DECLARATION ,sass,•
i heroby affirmavert that have a certificate pfenmaitto ncself e•a, ,r+e, APPLICATION FOR PLUMBING PERMIT {�
tenure,or a certificate of Workers'Compensation Insurance,or �, �J
a ceLrt�t(`i/j�d4copy thereof(Sec 33 a C) COUNTY OF L ANG ES BUILDING AND SAFETY
Polity N6 ` yo ioComp L p}�,�
❑ Certifi py a hereby furntshed'"'r�o F&44- FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING r �—
ADDRESS a
Certified copy 8 filed with the county building wp Nl1MBER FIXTURE OR ITEM • FEE
WATER CLOSET LOCALITY s7T� C
Date t"j) Apphc EAR6111
BATH TUB 3 CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS _
COMPENSATION INSURANCE SHOWER OWNS M
�� LAVATORY MAIL r1 S
(This wctton need not be rnmpkted J the work ten MAILADDRESS �]()
by the permit n for Dile hundred doBaro ($100) m leas) SINK ,3 CITY " TEL 7r a
1 certify that in the performance of the work for which this DISHWASHER ,3 CON7RACT0 8
permit n Issued, I shall not employ any person In any manner
so as to become subject to the Workers'Compensation Laws CLOTHES WASHER .3 ADDRESS '3 O
Date Applicant SWIMMING POOL RECEPTOR 15
NOTICE TO APPLICANT If, after making this Certificate of CITY 4a TEL N k 97 W
Exemption, you should become subject to the Workers LAWN SPRINKLER SYSTEM d
Compensation provisions of the Labor Code, you must forth STATE yy��o LIC C� i
with comply with such provisions or this permit shall be WATER HEATER 3 LICENSE NOO��r CLASS l..
deemed revoked ' GAS SYSTEM OUTLETS 3 DISTRICT NO PRO ESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER <
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Bust FINAL
nese and Professions Code and my license s VALIDATION in full force and DATE 4—f 0 ""(�r
effect
F
License Numb 7 Ltc Class �"3� BVINAL -df
Contrecto�j'r�\fLr(As-S Data 11-101—S-6
0 I am exempt from the licensing requirements as I em a Plan Check fee r^� �`r•U�
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ ..?
acting in my professional capacity (Section 7051, Bus S�
mess and Professions Code)
TOTAL FEE
Lic or Reg No Date Plan cheek applicant
HOMEOWNER-BUILDER DECLARATION Name
1 hereby affirm that 1 em exempt from the Contractor's Address '
License Law for the followmg reason (Section 7031 5, Bust City Tel No
nese and Professions Code)
I, as owner of the property, am exclusively contracting 3 3 0 21 A
with licensed contractors to construct the project
(Section 7044, Business and Professions Code) # • • • • • 5
CONSTRUCTION LENDING AGENCY 2 - - 4200
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
a2ooQ
insect(Sec 3097.Civ C>
Lenders Name 1. 1 2-80
Lender's Address
I certify that I have read this application and state that the
above information s 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 in ion purpose
Signature of Permittee Date