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HomeMy Public PortalAbout4853 AGNES AVE_Plumbing_8/18/1989_fixtures WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 20 0026 DPW 6/87 insure or a certificate of Workers Compensation Insurance 76A667A or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS Policy NoIO-0489604 Company CNA Ing. Ca- Certified copy is hereby furnished ` T FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING © _4853 es Ave Certified copy is filed with the county building inspec ADDRESS tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY T le Cit Date 16-89 Applicant Owen BKOS Plbg— WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS D BATH TUB CROSS ST COMPENSATION INSURANCE OWNEROwen Deval • ( . (This section need not be completed if the work Involved by a SHOWER the permit is for one hundred dollars($100)or less) MAIL�0 ADDRESS 2035 S Myrtle Ave I certify that in the performance of the work for which this permit is issued I shall not employ any person in any manner SINK — CITY MOnrav a TEL NO so as to become subject to the Workers Compensation Laws ( DISHWASHER CONTRACTOR 04Jen BIOS pUMbirM, IAC Date Applicant ( CLOTHES WASHER ADDRESS 4265 N Baldwin Ave NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR Exemption you should become subject to the Workers CITY El Nbnte TEL NO 443-0078 Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC deemed revoked WATER HEATER LICENSE NO 231 741 CLASS C36-20 LICENSED CONTRACTORS DECLARATION / �RICT NO „PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS l _1TI/JY (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER / and Professions Code and my license is m full force and effect 5 PER SYSTEM CO FINAL VALIDATION License Number 231 714 Lic Class 1216-20 DATE G U � Contractor Owen Bros P1bQ Date 8-16-89 FINALBY r Q ❑ I am exempt under Sec VW� B&P C for this reason p� Plan check fee ® � Date PLUMBING PERMIT ISSUING FEE$ , Z Signature TOTAL FEE 'a SINGLE FAMILY Plan check applicant HOME OWNER BUILDER DECLARATION Name ACM C . I hereby affirm that I am exempt from the Contractor s License t7e Law for the following reason (Section 7031 5 Business and Address 3(r 112.50 Professions Code) r City Tel No 1� , , 'a 3 ❑ I as owner of the property will do the work and ttie structure is not intended or offered for sale (Section ® TOTAL 112.50 7044 Business and Professions Code) I CONSTRUCTION LENDING AGENCY ` , . �� , CW�i 112.50 1, I hereby affirm that there is a construction lending agency for ` �i�i the performance of the work for which this permit is issued E .Vv (Sec 3097 Civ C ) 6 p Lender s Name almo—W X11 $/188 Lender s Address 5159 1 nit 9:17 1 certify that I have read this application and state that the above information is correct I agree to comply with all County ordinances and State la regulating Plumbing and hereby ,cWth r presentativ s f this County to enter upon the ve lone o r for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 8-16-89 nature of PerrWee Date