HomeMy Public PortalAbout9158,9152 BROADWAY_Plumbing__ WORKERS'COMPENSA710N DECLARATION
APPLICATIONvFOR PLUMBING P� MIT
.I hereby affirm that I have a certificate of consent to self 200026 DPW 6/87
insure, ar a certificate-of Workers' Compensotioh Insurance, 76A667A
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No.10—(4896(Y.Company (NA Tnc ranrP('n
❑ Certified copy is hereby furnished. BUILDING
® FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the county building inspec- ADDRESS 91 BrQadway
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Dote 5-10-90 Appli4ant 01a n Rrns PlIinning Inc WATER CLOSET i TeDTDIe CIC
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB5P 1 CROSS ST.
COMPENSATION INSURANCE '
/
(This section need not be completed II the work Involved by SHOWER OWNER Owen DevelOpertent
the permit is for one hundred dollars($100)or less.) LAVATORY MAIL
I certify That in the performance of the work for which This ADDRESS
2035 S. aZrrlp
C�
permit is issued, I shall not employ any person in any manner SINK CIN I4mrovia O4 TEL. NO. 359-3211
so as to become subject to the Workers'Compensation Laws. / DISHWASHER S�
coNrRAcrobWen Bros Plurbinp, Inc.
Date Applicant CLOTHES WASHER ADDRESS 4265 N. Baldcain Ave.
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY EI Monte CA TEL, NO.443--0078
With comply with such provisions or this permit sholl be 9
deemed revoked. WATER HEATER CT LICENSE NO. 231-741 'CWSS C36-2o-I6
LICENSED CONTRACTORS DECLARATION / -JU DICT NO. R SED BY
I hereby off irm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business / OUTLETS OVER r 0 121
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM c-21 0 O FINAL VALIDATION a
license Number 231-741 Lic. Class C16-201 ' Q DATE 0,
V.
FINAL 0
Contractor Owen Br05 Plu[nbiLTe Dote 5-10- 0
90 BY
❑ I am exempt under Sec. U
B.BP.C. for this reason a'
Plan check fee DOr)c
Dote: PLUMBING PERMIT ISSUING FEE$ %� Z
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY 5
HOME OWNER-BUILDER DECLARATION Name
1 hereby affirm that I am exempt from the Contractor's License Address
ACCT.i
Law for the following reason (Section 7031.5, Business and
ProfessionsCode): - . . 7
❑ City Tel. No. .r.�(]7 165.0D
t, as owner of the property, will do the work and the 1 ITEMS
structure is not intended or offered for sole (Section
7044, Business and Professions Code). " "' DTOTAL ' 165 e OO
CONSTRUCTION LENDING AGENCY CHECK 165.013I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CHANGE
(Sec. 3097, Civ. C.). .[I[1
Lender's Name 1]I]Qi]-1]Q01 5/1590
Lender's Address
I certify that I have read this application and state that the O 11677 1 AM 7'46
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
o thorize representatives of this County to enter upon the
ave- onedrap for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
s-10-90
4n.Awre of Perm t e r Dote