HomeMy Public PortalAbout9158 BROADWAY_Plumbing__ WORKERS t I hoveJSacION.cate of konse APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I hove a certificate of Consent t0 self 20-0026 DPW 6/87
insure, or a certificate of Workers' Com pensalion Insurance, 76A667A
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS '
Policy No. 10-0489604 Company CNA INSURANCE CK). .
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR-TYPE) BUILDING -
Certified copy is filed with the county building-inspec- ADDRESS 9158 Broadway
NUMBER FIXTURE OR ITEMFEE LOCALITY T le 01t
. - tion deportment. 2g @ �
Date -5-10-90 A li antMnBros P Irig,_lnc o1 WATER CLOSET 7r
PP S NEAREST,
CERTIFICATE OF EXEMPTION FROM WORKERS' p3- BATH TUB _ CROSS ST.
COMPENSATION INSURANCE t
(This section need not be completed If the work Involved by SHOWER - ' 'I OWNER Duren OeVelO [R'-Rt 1
the permit Is for one hundred dollars ($100)or less.) J 6AVATORYD MAB
W
I certify' that in the performance of the work for which this ADDRESS 2035 S. FWrtle(
permitis issued, I shall not employ any person in any manner r� SINK •i CITY 1"IODTOVla CAA TEL' NO 359-321 1
so as to become subject to the Workers'Compensation Laws. DISHWASHER D
CONTRACTOROwen Bros PILubing, Inc.
Date Applicant / CLOTHES WASHER ' lD ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR ' 4265 N. - ldW1R AV
Exemption, you should become subject to the Workers' CITY r Sl TEL. NO.
--
Compensationprovisionsof-the-Labor,Code,.you must forth- _ _ LAWN SPRINKLER SYSTEM -_ -
with comply with such provisions or this permit shall be -- - '-
deemed revoked. STATE-T - _- _ --` 'LICr -
LICENSED CONTRACTORS DECLARATION WATER HEATER 1 f1 LICENSE NO. 231-741 CV+55 -
- V DISTRICT NO. PR ESS BY
I hereby affirm that I am licensed under provisionsofChapter 9 GAS SYSTEM OUTLETS _Zj J 16
0(commencing with Section 7000) of Division 3 of the Business / OUTLETS OVER
�19and Professions Code,and my license is in full force and effect. 5 PER SYSTEM T FINAL VALIDATION a.
License Number 231-741 Lic. Class 2,36-20-16 v`- DATE :O O:
U.
FINAL
Contractor Olen BrOS P7 t_mi ine Date_ 5-10-90 0T l O'
❑ /I am exempt under Sec. 1-4
BAP.C. for this reason Plan check fee y
Date: Z•
PLUMBING PERMIT ISSUING FEE$
Signature _
TOTAL FEE
- Plan check applicant --
SINGLE FAMILY -
HOME OWNER-BUILDER DECLARATION Name `I
I'hereby affirm that I am exempt from the Contractor's License gddress -- '- ACC•T.i
Law for the following reason (Section 7031.5, Business and 331037
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the - - _ . . 1 ITEK
structure is not intended or offered for sale (Section _ .. . � m ��
7044, Business and Professions Code). TOTAL 1bs
®
CONSTRUCTION LENDING AGENCY CHECK - 165.011
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued -- CHANGE , .013
(Sec. 3097, Civ. C). -
Lender's Name 0000-011FI1 5/15/90
Lender's Address /]676 1 AM7.7k1f
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
a Ihorize repreien1cn ve of this County to enter upon the
a oned' rop for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
5-10-90
Signature of Permik4e Date