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tS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
• ,I hereby; affirm that I have a certificate of consent to self 76A667A
insure, or a cl;tificote.of Workers' Compensation Insurance, CE 817(REV. 10/81) �J
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
0 cy No. #0489604 Company Cont;n n a 1 asualty
Certified copy is hereby furnished.® BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 4906 A es
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY Temple City
Date 1-27-87 Applicant Owen Bras. Plhg_ WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER Tom Ercanbrack
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS 2121Valderas Dr.
I certify that in the performance of the work foi which this
permitis issued, I shall not employ any person in any manner SINK CITY Glendale TEL. NO. 957-1481
so as to become subject to the Workers'Compensation Laws. DISHWASHER
1'» CONTRACTOR Owen BrOS. Plumbing, inc.
Date Applicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4.265 N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY E1 Monte TEL. "°
LAWN SPRINKLER SYSTEM ' 443-0078
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. 231 741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION v DISTRICT NOS, PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS CnJ /Q(J
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
DATE
License Number 231 741 Lic. Class l'3 r) 0
FIN U,
Contractor OWen RmG- P1 hcrDate 1-27-87 B
❑
I am exempt under Sec. O
B.BP.C. for this reason ;2'6 4 IL 9 A w
Plan check fee # o 0 0 0 0 5 �
Signature 4 - 0 1
Date:
PLUMBING PERMIT ISSUING FEE$ �`� 6;5 0 z
TOTAL FEE 0 0 0 1 6,5 0 =
U
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name 01.3o.-87
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.
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
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
authorize representative of this County to enter upon the
h ned pr,
r p or inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
1-27-87
signature of Permit a Date