HomeMy Public PortalAbout4857 AGNES AVE_Plumbing_8/18/1989_ ' 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 ) I COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No 1(�fY�806MCompany CNA Ins. GQ-
❑ Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ADDRESS 4857 Agnes Ave
❑ Certified copy is filed with the county building inspec
tion department INUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple Cit Q
Date 8-16-89 Applicant Owen Bros PlbeWATER CLOSET A O —� NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB .'2 r CROSS ST
COMPENSATION INSURANCE SHOWEROWNER �_
(This section need not be completed if the work Involved by MAIwen DPy L
mPnt
the permit Is for one hundred dollars($100)or less ) LAVATORY O ADDRESS 2035 S Myrtle Ave
1 certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner I SINK — CITY Monrovia TEL NO 359-3211
so as to become subject to the Workers Compensation Laws DISHWASHER
--' CONTRACTOR Owen Bros Plumbing, Inc
Date Applicant CLOTHES WASHER r ADDRESS 4265 N Baldwin Ave
NOTICE TO APPLICANT If after making this Certificate of
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth CITY E1 Monte TEL NO 443-0078
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO 231 741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9
GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER `�
and Professions Code and my license is to full force and effect 5 PER SYSTEM FINAL VALIDATION
License Number 231 741 Lic Class 1236-20 DATE �Aqhvfip
FINAL
Contractor Owen Bros. PlOwen Bros. P1hgDate 8-16-89 BY O
❑ I am exempt under Sec 0
B 8P C for this reason N Plan check fee
Date PLUMBING PERMIT ISSUING FEE$ o , Z
Signature
TOTAL FEE �a
SINGLE FAMILY
Plan check applicant
r1
HOME OWNER BUILDER DECLARATION Name ACC
I hereby affirm that I am exempt from the Contractor s License Address N<\TA
Law for the following reason (Section 7031 5 Business and
Professions Code) Cit Tel No 3307 `� 112.I50
❑ I as owner of the property will do the work and the y {# 1 1 '1v ITEMS.1 s k �
structure is not intended or offered for sale (Section
No. TOTAL 1.�. r-�O
7044 Business and Professions Code)
r
CONSTRUCTION LENDING AGENCY ,, ,� tl y� t (HE(K,1 112■5[I
1 hereby affirm that there is a construction lending agency for �
the performance of the work for which this permit is issued Ctu�AIA ■00
(Sec 3097 Civ C )
Lender s Name ,
opo-000i 8/13/89
Lender s Address 5161 1 AM 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
ordin nces and State laws regulating Plumbing and hereby
%Qmigzrize r r sentatives o is County to enter upon the
ve e d prop ty r nspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
8- 6-89
Si nature of Perm We Date �