HomeMy Public PortalAbout5926ALESSANDRO AVE_Plumbing i
WORKERS' COMPENSATION DECLARATION . APPLICATION FOR PLUMBING PERMIT
ppp-. ;!"he y 'affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. 10-O'48960&mpany CNA Ins. Co.
❑ Ce(tified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 5926 Alessandro
`rtified copy 's led with the county building inspec-
dIh NUMBER FIXTURE OR ITEM @ FEE LOCALITY
oma, Temple Ci
Dated Applicant Owen Bros. Plmb. WATER CLOSET s NEAREST
ty
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB i CROSS ST.
COMPENSATION INSURANCE . OWNER Ralco, Inc.
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars $100 or less. MAIL
P ( ) 5 LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner 5 SINK CITY Temple City TEL. NO. 287—1459
so as to become subject to the Workers'Compensation Laws. DISHWASHER ^
coNTRAcrR5wen Bros. Plumbing, Inc.
Date ApplicantCLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N. Baldwin A
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY El Monte TEL. No. 443-0078
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. 5 WATER HEATER LICENSE NO23 1-74 1 CLASS C36-20
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
GAS SYSTEM OUTLETS
I hereby affirm that I am licensed under provisions of Chapter 9 /
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
OF
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
231-741 C36-20 (Q DATE O
License Number Lic. Class 0
FBY
ContractorOwPn BYnR- Pl mh-Date 1-9-RA 0
❑ I am exempt under Sec. / PI
CI
B.BP.C. for this reason ` cul
Plan check fee en
Date: PLUMBING PERMIT ISSUING FEE$ 6
Signature
TOTAL FEE
Plan check applicant �_1.i 7
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address ~1' ;=i_ 1 = '
Low for the following reason (Section 7031.5, Business and I --B••'L 6 a --s.x
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 ® a__
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY (ia_i�t—
I hereby affirm that there is a construction lending agency for - 'Y^7w,7,
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 lows regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-m t" ned"property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permitte Date