HomeMy Public PortalAbout5750ALESSANDRO AVE_Plumbing ION
DECLARAT
..r' f WOPKt'R'SCOMPENSATate of consent to 76A666DPW9/89 APPLICATION FOR PLUMBING PERMIT
76A667A
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.)
Policy No.
1004 CNA .ins. Co. COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
❑ Certified copy is hereby furnished. BUILDING T
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS -S7SO AleSsanClrO
ID Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY TeM le Cit
Date Applicant OWQp- $r=cm_J?lmh WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) OWNER
I certify that in the performance of the work for which this permit LAVATORY
is issued, I shall not employ any person in any manner so as toMAIL
SINK
become subject to the Workers' Compensation Laws. ADDRESS 88.12 E. Las TL1naS .Drive
DISWASHER CITY 'San Gabriel TEL.NO. _
1131
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR
Owen Arc).- PlInhing
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS 426'55 N. Baldwin Avenue
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY El Monte TEL.NO. 443-0078
1 hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER KL
(commencing with Section 7000) of Division 3 of the Business and STATE LIC.
Professions Code,and my license is in full force and effect. 1 GAS SYSTEM 1 OUTLETS ,5 LICENSE NO.231 741 CLASE36-20-1 6 0
OUTLETS OVER DISTRICT NO. PROCESSED BY
5 PER SYSTEM
License Number 231 741 Lia CIa6-20-16
FINAL VALIDATION �
DATE i< ` -$�G�
Contractor( en Bzos. P1mb Date 06R—_40 9� 0j
❑ FINAL
I am exempt under Sec. BY
B.&P.C.for this reason
Date: Plan check fee d ,
PLUMBING PERMIT ISSUING FEE$ go
Signature
❑ TOTAL FEE
Plan check applicant �ifJ4
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
1 hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Address 'r=.+
Code): :rte:?! 23 ai_li_,
El 1,
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 --HHAI, 29 00
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
a ntati ,Xf this Cop o enter upon the above-mentioned
rty f f'rss ection p se SEE REVERSE FOR EXPLANATORY LANGUAGE
j8-30-91
4-CAW4-
SIgNature of Pe tee Date