HomeMy Public PortalAbout5926 ALESSANDRO AVE_Plumbing__ ',.��V�yORKERS'COMPENSATION DECLARATION , APPLICATION FOR PLUMBING PERMIT
1 hereby affirm that I have a certificate of content to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
•or a certified copy thereof-(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. I0-04R &Xompany CNA In_ Co OL iirZ
Certified copy is hereby,furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 5926 Alessandro
❑ Certified copy filed with the county building inspec-
rSm NUMBER FIXTURE OR ITEM @. FEE LOCALIT
Date -� ApplicontOwen Bros.Plmb. tWATER CLOSET y NEAREST Temple City
C'j
CERTIFICATE OF EXEMPTION FROM WORKERS' lo BATH TUB
CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER Ralco Inc.
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL
'� � ADDRESS 9403 E. Las Tunas
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY Temple Cit TEL. N0.287-1459
so as to become subject to the Workers'Compensation Lows. DISHWASHER
CONTRACT06Wen Bros, Plumbilig, In
c.
Date Applicant CLOTHES WASHER I ADDRESS 4265 N. Baldwin Ave.
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY E1 Monte TEL. No443-0078
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE No.231-74 1 CLASS C36-20
LICENSED CONTRACTORS DECLARATION 5 rDISTRICT pK�. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS i✓� lfI/7 oV
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION CQO
License Number 23 1-74 1 Lic. Class C36-20 DATE
C�.
FINAL
Contractor Owen Bros. PlmbDcite 1-9-89 BY
❑ I am exempt under Sec. VV
B.BP.C. for this reason
Date: Plan check fee ® ��
PLUMBING PERMIT ISSUING FEE$ O
Signature
TOTAL FEE ��
_.
SINGLE FAMILY
Plan check applicant �.._,.
•.7•�:.::• T�`�,=tE_i
HOME OWNER-BUILDER DECLARATION Name r
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address 'fig';" �(3'•'�I
f L m - i
�
Professions Code): City Tel. No. }.��}... ,I-, ;t�
❑ 1, as owner of the property, will do the work and the L .
structure is not intended or offered for sale (Section lIil; (3j I(
7044, Business and Professions Code).
�»
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for i�l`.l„ir -f jE i7' 0
the performance of the work for which this permit is issued ,
(Sec. 3097, Civ. C.). �= Art :3 F;`
L.i
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
authorize representatives of this County to enter upon the
bove m ntioned pr rty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Perm tee Date