HomeMy Public PortalAbout4847 1/2, 4855 AGNES AVE_Plumbing_8/18/1989_bathroom fixtures, water heater, gas system, outlets 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 No 10-01+89fi(YaCompany (TSA Tnc_ ('n_ \ ,� \ �_ - �+
Certified copy is hereby furnished ~�~ ` `y`
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec ADDRESS
tion department NUMBER FIXTURE OR ITEM FEE
P LOCALITY Temple City' �
Date 5-16-89 Applicant Owm Bros_ Plhg_ �j WATER CLOSET (In✓ NEAREST `
CERTIFICATE OF EXEMPTION FROM WORKERS a BATH TUB CROSS ST +
COMPENSATION INSURANCE SHOWER Owen OWNER ' nt
++ — Develo
(This section need not be completed if the work Involved by MAIL 2035 S tle Ave
the permit Is for one hundred dollars($100)or less ) LAVATORY Q — ADDRESS
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY M7nrovia TEL No 359-3211
so as to become subject to the Workers Compensation Laws DISHWASHER
rp CONTRACTOR Owen BrOS Plulnbing, InC
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of 4265 N Baldw:Ln Ave
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM CITY El Monte TEL No443-0078
:�j
with comply with such provisions or this permit shall be STATE 231 741 LIC 036-20
deemed revoked WATER HEATER /_ LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION �O DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 / GAS SYSTEM OUTLETS ✓ ;
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER ��..
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL VALIDATION
License Number 231 741 Lic Class 036-20 DATE O
U
FINAL
Contractor aqen Bros Plbg Date 8-16-89 BY
O
❑ I am exempt under Sec W
B 8P C for this reason i
Plan check fee ► Z
Date
Signature PLUMBING PERMIT ISSUING FEE$ 5
TOTAL FEE
SINGLE FAMILY Plan check applicant +
HOME OWNER BUILDER DECLARATION Name ACCT.L
I hereby affirm that I am exempt from the Contractor s Address License AddI
Law for the following reason (Section 7031 5 Business and 3307 112.50
Professions Code) City Tel No A,• 1` ITEMS �
❑ 1 as owner of the property will do the work and the
structure is not intended or offered for sale (Section TOTAL 112 50
7044 Business and Professions Code) �y
CONSTRUCTION LENDING AGENCY + �' * \ + `+ bi 1 +i} (HECK %A ti 112i�J
'I hereby affirm that there is a construction lending agency for CH .(XI
the performance of the work for which this permit is issued
(Sec 3097 Civ C )
Lender s Name 0000-ml 8/18/89
Lender s Address 51b0 1 All 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 10.
ordinancete jaws regulating Plumbing and hereby
t7&ftrop
tatives of is County to enter upon the
eer y f spectionpurposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
8-16-89
Si nature of Permittee Date