HomeMy Public PortalAbout9435, 9437, 9441 BROADWAY_Plumbing__ WORKEREI COMPENSATION DECLARATION - - - -i
1116"
hereby nffurp that l have a certificate of•consenl to self m p-0046 DPW^,Blr. .,.APPLICATIONFOR -PLUMBING PERMIT
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sure;or o certificate of Workers'C6A667Aompensation Insurance,ora CE 17(REV 8/86) -
certified copy,lkereof.(Sec. 3800 Lab C )..,,
.COUNTY OF LOS ANGELES' -,' `DEPT '
Policy-N,. 10-0489.604ompany. CNA Ins. Co - \ OFPUBLIC WORKSVi
. a.' ••
O..•'Lertihedsoay,is hereby furmshed3
\• ^s `. .
' - 'FOR APPLICANT TO FILL IN(PRINT OR TYPE) - BUILDING
® Certified copy is filed with the county building inspection - ADDRESS -
-department. - `�. NUMBER FIXTURE OR ITEM @ FEE,. 9435 & 9437 Broadway.
- ..-. . ,. LOCALITY'
T)
Temple Clt
1-25-89
Doie •gpphcam Owen Bros: PlbgWATER CLOSET(TOILET)
. _ z NEAREST - -
's - 1 O o BATHTUB ' -7 _ CROSS ST. '
_ .•�; 'CERTIFICATE OF EXEMPTION FROM'WORKER$` - - :. .. - ' - 2
COMPENSATION INSURANCE . ' - 7-1 ' • - OWNER ~ "
- .SHOWER " D&A ConstPucEion '
. '(This section need not be completed If theTwe' involved by, - _ - ,
the permit is for one hundred dollora'($100) or less:) '; .LAVATORY,'' „^7 MAIL .-
G ADDRESS '' 150 N. Santa Anita Ave`. 1k4Z
hcertify that in the performance of the work for.which this per SINK - '
mit is issued, I shrill not employ any person'in any.manner so .- ' �. CITY TEL.NO
Arcadia 447-5641
".as to.become subjecPto the-Workers{ompensotion'Law4. - DISHWASHER. `" i - -- -
m - CONTRACTOR
Ddte' Applicant CLOTHES WASHER. 11 %
ADDRESS.. 4265 N. BaPdwin Ave.
NOTICE TO APPLICANT: If, after mokmg this Certificate of{x- SWIMMING POOL RECEPTOR
em'ption;you should become subject to the Workers"Compen I CITY TEL N0443-0078 -
sation•provisionsof the,tabor Code,you 4iust forthwith comp -LAWN SPRINKLER SYSTEM r - `EI Monte
ly with such provisions or this permit shall be.deemed revok � � -�• . - - STATE LIC. '•
ed.' • 6 - - ,. WATER HEATER i LICENSE NO. 231 741 CtA55 C36-20
'-"+ ❑LENSED CONTRACTORS DECLARATION - DISTRICT No. P CESSED BY '
I hereby affirm-that9.o1 licensed underprovis ons of-Chapter,' GAS SYSTEM OU TS
9(commencing with Section 7000)of Division 3,of the Business OUTLETS OVER V
and Professions,Code, and my,license is in full foree'.and of-• - SPIER SYSTEMFINA '
feet: . . y _ - .. _- DATE -�7�J VAI ATION a.
License Humber--2'31 74T, Lie Class C3h 10 V
.. FINAL K
Contractor
Owen Brnc ^P1ho0me 1 75--R9 _ — - BY �"�j
.c H
_aO ayam exempt under Seca - . _ {•L,-Tot - W
B 8P C for this reason - - Plan check fee - ® ILL` ;.I Z
PLUMBING PERMIT ISSUING FEES L IrCE
,.Signature - .4!7F 3.'i'�. m
` - - - TOTAL FEE ��O1
-1 T 50
SINGLE FAMILY ,_. _ .. •,. ll��{:.. - y4r)L
'HOME OWNER-BUILDER DECLARATION Plan check applicant.. -
. I hereby affirm thold am exempt'. rom the Contractor's:License ,Name ', =1-IE�. "
Law-for the following.reason (Section 7031.5,:Business,and -_ - `' —• + - -
Professions'Code)' Address.
as owner of t,
he will d6 the workand the City' - Tel. No. {` "_ i- .-
structure isnot intended or offered for sale(Section 7044; a-4
Business Business and Professions Code)
CONSTRUCTION LENDING AGENCY - -
hereby.offirm:that there is o construction.lending ogency:fon' �•2
the performonce of the work-forwhich this.permit is issued`
(Sec..3097 Civ. C.). r - -
Lender's Name
Lender's Address:
Icertify that I hole read this application and state that the
above informciticn is correct. I agree to comply with all County - -
ardinances and State jaws.regulating Plumbing, and-hereby,
&0entioned
rize-representatives of this• County to enter upon the r - -property for inspection'purposei.-'1=25-89 SEE REVERSE=FOREXPLANATORY LANGUAGElure of Permittee :Date,' - - -