HomeMy Public PortalAbout4859 AGNES AVE_Plumbing_8/18/1989_bathroom fixtures, water heater, gas systems, 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 No104489604 Company CNA Ins. Co.
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
El `Q ,
Certified copy is filed with the county building inspec- ADDRESS 4 eS'Ave.
tion department. NUMBER FIXTURE OR ITEM @ FEE
JJ LOCALITY Temple City
Date 8-16-89 Applicant OWED BrOq- PlbR_ WATER CLOSET (p NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWEROWNER Owen Developmenb.
(This section need not be completed if the work involved by O MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY C) ADDRESS 2035 S. Myrtle Ave.
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK �� ,CITY Monrovia TEL.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
00 CONTRACTOR Owen Bros. Pltanbing, Inc.
Date Applicant CLOTHES WASHER bo ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY El Monte TEL. N0.443-0078
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC C36-20
231 741
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION O DISTR�T NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 15 PER SYSTEMu DATE FINAL VALIDATION >
License Number 231 741 Lic. Class x'16-7(1 ,JJ&d 0.�
FINAL
Contractor Owen Bros. Plbg. Date 8-16-89 BY
❑ I am exempt under Sec. 1 ��
B.&P.C. for this reason
ck fee
Plan che ® en,
Date: PLUMBING PERMIT ISSUING FEE$ r
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name 5
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address AC' oQ
Professions Code): City Tel. No,, 33071q20.50
❑ 1
I, as owner of the property, will do the work and the 1 ITEMS
structure is not intended or offered for sale (Section a 1
7044, Business and Professions Code). ` ®e , TOTAL 2.2� �0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CHECK
112.50
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). CHANGE oCt[I
Lender's Name
Lender's Address
0-001 4�1V/V7
I certify that I have read this application and state that the ® 5162 1 An 9a 17
above information is correct. I agree to comply with all County
4gnature
dinances and State la s regulating Plumbing, and hereby
thori eprese ativ of this County to enter upon the
ov 1,0rte p rt for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
8-16-89
of Per ttee Date