HomeMy Public PortalAbout5025TEMPLE CITY BLVD_Plumbing (2) WORKER have a ENSATate of consent to oPw9/e9 APPLICATION FOR PLUMBING PERMIT
I hereby atllrm that I have • certificate of consent to self Insure
r
or'a certificate of Worker's Compensation Insurance or a cenllietl
copy thereof(Sec 3800 Lab C) ,- - -• - I `
Policy No 10-048960' Camperty CM IPS CO COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
Cen,fled copy Is hereby fummhetl
FOR APPLICANT TO FILL IN(PRINT OR TYPE) - BUILDM
5025 Temple City Blvd
Certified copy is filed with the county bulltling inspection
department - NUMBER FIXTURE OR ITEM ; LOCALITY Temple City
Data 1-31-92 Appecam Owen •Bros Plbg WATER CLOSi NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERSBATH TUB CROW ST
COMPENSATION INSURANCE ASSESSOR 1- -
(This section need"I be completed If the work Involved by the SHOWER - -- - IAAF BOOK PAGE PARCEL
permit to for one hundred dallare(3100)or leu)' LAVATORY OWNER Premier Const.
I certify that in the performance of the work for which this permit
Is Issued I shell not employ any person in any manner so as toSljd( MAILIADDP 0 BOX 427
become subject to the Workers Compensation Lowe
DISWASHER _ CITY Rosemead TEL No 308-0030
Date Applicant CLOTHES WASHER CONTRACTOR Owen Bros Plumbing, Inc M
NOTICE 70 APPLICANT If after making this Certificate of 8t
Exemptlon you should become sublect to the Workers Compensation SWIMMING FOOL RECEPTOR
provisions of the Labor Code you must forthwith comply with such ADDRESS 4265 iN Baldwin Ave
provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION WATER HEATER E1 Monte TEL No 443-0078 }a
I hereby affirm that I em licensed under provisions of Chapter 9-
(commencing with Section 7000)of Division 3 of the Business and ST
Professions Cade and my license is in full force and effect GAS SYSTEM OUTLETS _ LICENSE NO 231 741 CLASS C36-20-16
OUTLETS OVER DISTRICT NO PROCE89ED BY I=
6 PER SYSTEM O
Llcerree Numt»r 231 741 Ltc clam C36-2(N16
FINALs- Z 9 VALIDATION a
contractor Owen Bros. Plbm Data 1-31-92 DAA
❑
Z I am exempt under sec FINAL ,Z
By
B 8P C for this reason -
Daze Plan check tee _ Poo.
Slgnetum PLUMBING PERMIT ISSUING FEE$
❑ TOTAL FEE _ -
1'- 1 e T
Ran check applicant
SBFAMILY
HOME OWNER-BUILDER DECLARATION
Name -
1 hereby affirm that I em exempt from the Contractor's License Lew
for the following reason (Section 7031 5 Business and Professions Address -- -
Code) City Tel No _ _ ,O"2
- 95
❑ I as owner of the property will do the work and the structure
Is not Intended or offered for sale (Section 7044 Business r "�•y=
and Professions Code)
CONSTRUCTION LENDING AGENCY -
I hereby affirm that there is a construction lending agency for the [lf( 4
performance of the work for which this permit Is issued (Sec 3087 - - , - - - -� Q[lQl .✓ r-'_
av C) j`Z7 1 AM 132
Lenders Name ,
Lander s Address
I certify that I have read this application and state that the above - I
Information It correct I agree to comply with all County ordinances ,
and eta 14W regulating PI burg and hereby authorize -- - - - -
re nudiv rs Coo t e r upon the above mentioned
Try or
it Pur BEE REVERSE FOR EXPLANATORY LANGUAGE - " -
wiiA 1-31-92
sic
nature of Perm a Date -