HomeMy Public PortalAbout4851 AGNES AVE_Plumbing_8/18/1989 WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �7
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 No 10-&4996(yiCompany M InsCo
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
®
Certified copy is filed with the county building inspec ADDRESS 4851 es Ave
tion department NUMBER FIXTURE OR ITEM @ FEE
_ LOCALITY Temple City
Date 8-16-89 Applicant men BIOS Plbg 3 WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST +
COMPENSATION INSURANCE SHOWER OWNER i Owen Devel t
(This section need not be completed if the work involved by '�- MAIL
the permit is for one hundred dollars($100)or less) LAVATORY 3 ADDRESS 2O S $ ' T tie 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 Monrovia i TEL NO 359-3211
so as to become subject to the Workers Compensation Laws `
DISHWASHER CONTRACTOR
Own`Bros Piumbirig, Inc
Date- Applicant CLOTHES WASHER ' 7 i
NOTICE TO APPLICANT If after making this Certificate of ADDRESS
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth CITY El Monte TEL No 443-0078
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATELIC
deemed revoked WATER HEATER -- LICENSE NO' 231 741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION DISTRICTrNO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS J�
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER �.
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL J�� VALIDATION p:
License Number—-231 741 Lic Class 123+-90 DATE (/ 8
FINAL �y �
Contractor Owen BIDS_ Plhg_ Date R-1 6—AQ BY O
❑ I am exempt under Sec (�
W
B&P C for this reason
Plan check fee S z
Date PLUMBING PERMIT ISSUING FEE$ 0
Signature _
TOTAL FEE
SINGLE FAMILY
Plan check applicant °
�j
HOME OWNER BUILDER DECLARATION Name
416
I hereby affirm that I am exempt from the Contractor s License Address ACCTA
Law for the following reason (Section 7031 5 Business and
Professions Code) City Tel No k 3M7 112'511
I as owner of the property will do the work and the t1 ITEMS
�
structure is not intended or offered for sale (Section TOTAL 112.50
7044 Business and Professions Code) °
CONSTRUCTION LENDING AGENCY CHECK 112■50
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec 3097 Civ C )
Lender s Name 0000—Mi A8/18/89
M
Lender s Address , 5158 1 1�I 9:16I certify that I have read this application and state that the
above information is correct I agree to comply with all County
or finances and State la regulating Plumbing and hereby
thoriz re*0
f this County to enter upon the
bo a oned p ty or inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
8-16-89
igric of Perm ee IDate