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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