HomeMy Public PortalAbout5745 AGNES AVE_Plumbing_4/22/1961_ 1 WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
hereby affirm that I have a certificate of consent to self 76A667A if xm
ure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) 91
ora certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NoZ184-2379eampany Fremont Indemnity J
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
EZ Certified copy is filed with the county building inspec- ADDRESS -57-94—Agnes
tion department. NUAWR FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET Dv `Bem le Cit
Date 1-24—R4 Applicant nWP.TI RrOS PI} NEAREST A
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER d Construction
the permit is for one hundred dollars $100 or less. MAIL
P ( ) ) LAVATORY ADDRESS 1816. San Gabriel Blvd.
I certify that in the performance of the work for which this
permit is issued, I shall not employ an person in an manner SINK CITY TEL. NO.
P P v vP v OU San Gabriel 573-4110
so as to become subject to fhe Workers'Compensation Laws. DISHWASHER
Q CONTRACTOR Owen Bros. Plumbing, Inc.
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 426.5 N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO.
P P Y LAWN SPRINKLER SYSTEM E1 Monte ' 443-0078
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER O® LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED Y�
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
DATE � �°`?1d C�
License Number 231 741. Lic. Class 036-20 f
FINAL
Contractor OWPn Bros_ P1brDate 1-24-84 BYE "�
I am exempt under Sec. �
B.BP.C, for this reason Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE o
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name t C C
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and ;
Professions Code): City Tel. No.
❑ �1 :
I, as owner of the property, will do the work and the - �U
structure is not intended or offered for sale (Section \J
7044, Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY i
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
Lender's Address `
I 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 laws regulating Plumbing, and hereby v O :-
authorize representatives of this County to enter upon the \' O
e- tinned property for inspection purposes. f
SEE REVERSE FOR EXPLANATORY LANGUAGE 0
1-24-84
ign t re of Permittee Date