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Home My Public Portal About6357 TEMPLE CITY BLVD_Plumbing__ WORKERS'COMPENSATION have a TION DECLARATION cc 817 APPLICATI N FOR PLUMBING PERMIT {� I hereby affirm That I have a certificate of consent to self cc so (:+sl lJ insure, or a certificate of Workers'Compensation Insurance,or a certidc�fd��c y there`o`f(Sec 3800 Lab C) / COU NTY OF LOS ANGELES BUILDING AND SAFETY polis, / 100 0 mpany ..fig-/ ❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING c A` to Certified co NUMBER FIXTURE OR ITEM • FEE LOCALITY ADDRESS l s+ copy is filed with the county budding Inspe Date-e e LOCALITY Applicant WATER CLOSET NEAREST BATHTUB CROSS ST /,f CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER 4AkiCZAC, AV ATORV MAIL �s (Thea section need not be completed if the work involved ADDRESS —( L J D 1J by the permit Is CITY TEL N a for one hundred dollars ($100) or Irma) SINK 0. 1 certify that in the performance of the work for which this DISHWASHERU permit Is Issued, I shall not employ any person in any manner 3 CONTRACTO µ.g so as to become sublet[ to the Workers' Compensation laws CLOTHES WASHER ...3 ADORES J 0 Date ApplicanttSWIMMING POOL RECEPTOR / U NOTICE TO APPLICANT If, after making this Certificate of CIT.YS44CATEL Nl a Exemption, you should became subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC /i Compensation provisions of the Labor Code, you must forth LICENSE N, 7 CLASS ` z with comply with such provisions or this permit shall be WATER HEATER deemed revoked GAS SYSTEM OUTLETS DISTRICT NO PRO ESSED BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER ,� Q I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi FINA X ness and Professions Code, and my license a in full force and DATE ~� _V r VALIDATION effect C FINAL License Numb L¢ Class /] FBY I Contra" Date �`� �,r I am exempt from the licensing requirements as t am a Plan Check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEES acting in my professional capacity (Section 7051, Bus meas and Professions Code) TOTAL FEE Lic or Res No Date Plan chock applicant HOME OWNER BUILDER DECLARATION Name I hereby affirm that I em exempt from the Contractor's Address License Law for the following reason (Section 7031 5, Bull City TN No ness and Profeasiom Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project :23022A (Section 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 2 • - 4200 for the performance of the work for which this permit is Issued(Sec 3097,Civ C) • • a 42006 Lender's Name Lender's Address 1 1' 1 2-80 I certify that I have read this application and state that the above mformation 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 inspection pervolifs Sigmature of Permittee Date WORKERS COMPENSATION ate of consent to 70AW DPW afea APPLICATION FOR PLUMBING PERMIT I hereby affirm That I have a certificate of consent to Bell insure 7aAae7A or e cditificate of Worker a Compensation Insurance or a certified copy thereof(Seo 3800 Lab C) Palcomy4 _ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV No ❑ Cerbhed copy is hereby hnniemcl FOR APPLICANT TO FILL IN(PRINT OR TYPE) Al BUILDING GCertifiedCopyedCopy g filed with the county bwlMng Inspection ADDRESS departnard -' NUMBER FDOURE OR REM A FEE LOCALITY G Del App LSWA WATER CLOSET NEAREST CERTIFICATE OF EKEMPTION FROM WORKERSCROSS ST COMPENSATION PENSATN INSURANCE BATH TUB ASSESSOR MAP BOOK 3 PAGE PARCE 7 (This motion mad not be completed If the work Involved by the SHOWER permll to for one hundred dollars($100)or leu) LAVATORY OWNER jif I certify that in the performance of the work for which this permit MAIL Is issued I shell not employ any person In any manner so as to SINK yp ADDRESg become Subject to the Workers Compensation Laws DISWASHER CDY� TEL Date Appkant CLOTHES WASHERfS)HTfiACT NOTICE TO APPLICANT If after making this Certificate of ExemPtlon you should become subject to the Workers Compeneatlon SWIMMING POOL RECEPTOR provisions of the Labor Code you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CRY r�Ol. TEL NOw'of CL I hereby affirm that I am licensed under provisions o1 Chapter S WATER HEATER `1 (commencing with Section 7000)of Division 3 of the Business and �jCp SE NO [ CLASS Prolesslons Code,and my license is in full force and effect GAS SYSTEM OUTLETS OVER DISTRICT NO PROCESSED Y Q 5 PER 6`BTEM O License Nmb.WNWLIC Claes Conbecl Dete O � ' V r /IfiION 76.65 ❑ f I am mempt under Sec BVD 1 ITEMS B aP C for the reason lhr� TOTAL 70 . 65 Date Plan Check fee - 70.65 C}$CY. Signature PLUMBING PERMIT ISSUING FEESUwu ❑ TOTAL FEE SINGLE FAMILY Plan check applicant GOOD-000I HOME OWNER BUILDER DECLARATION Name rtVeVIeJV—VWS 5/24/9 I hereby affirm that I am exempt from the Contractor a License Lew M7 1 AM 8:*7 for the following reason (Section 7031 8 Business and Professions Address Code) ❑ Gly Tel No ' 1 es owner of the property will do the work arid structurethe structure Ie not Intended or offered for eels (Section 7044 Business ► and Professions Code) CONSTRUCTION LENDING AGENCY I hereby affirm that there IS a construction lending agency for the performance of the work for which this permit is Issued(Sec 3087 ON C) Lender•Name Leader a Address I certify that I have read this application and Hata that the above , Information Is correct I agree to comply with all County ordinances and State laws regulating Plumbing and hereby authorize representatives of this County to enter upon the above mentioned pr0peryjf!mS.LjWerten p rpo • SEE REVERSE FOR EXPLANATORY LANGUAGE Sidnahire of Permittee V Date