HomeMy Public PortalAbout9437, 9441 , 9445 BROADWAY_Plumbing__ yr _', ,'-•�I . •, r,' _ p
� 'rVORKERS••COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I herebaff irrp'that I have a certificate of consent to self in- X20-0026 DPW 4/87 �1
sure;or a certificate of,Workers'Compensation Insurance,are 76A667A '_ Lnlull
P
certified copgtihereof.(Sec 3800 Lab C ):-• .CE.BI7(REV. B/66) -
Pohcy•No: 10=048960(cmpany CNA Ins. Co. - COUNTY OF LOS-ANGELES. •. DEPT. OF PUBLIC_ WORKS :.
Certified copy is hereby furnished.
FOR-APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
X]. 'Certified copy is filed with the county building inspection a -ADDRESS 9443 &' 9445 BrOadwa
department. - NUMBER FIXTURE OR ITEM Ca --FEE LOCAIITV
WATER CLOSET(TOILET)„ • T m - -
Date 1-25-89 Applicant. Owen BIOS . Plbe. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB — CROSS ST.
' COMPENSATION INSURANCE OWNER D&A Construction
-
(Thlssactlon'naed'not be completed if'th¢work involved by SHOWER Z MAIL
the permit is for one hundred dollars (5100)or las:.): -LAVATORY ADDRESS 150 N. SAnta Anita Ave 1147
I certify that in the performohce of the work for which this per-
7-5641
mit is issued, I shall not employ any person-in any manner so p2. SINK - i CITU Arcadia TEL N044
as to become subject to the Workers"Compensation Laws.
DISHWASHER
CONTRACTOR Owen Bros. Plumbing, Inc. -
Date Applicant - CLOTHES.WASHER i -
NOTICE TO APPLICANT If;•6fter making this Certificate of Ex- ADDRESS •4265 N. BA1dWln Ave.
:WINNING POOL RECEPTOR
emption,yoashoulci become subject to The Workers'Compen- -
sation.provisions of the labor Cocie,.you must forthwith comp-r' - CITY El Monte TEL NO 443-0078
ly with such provisions or this permit shall be deemed reLAWN SPRINKLER SYSTEM vok- -' STATE LIC.
ed. ' . ' "7 - WATER HEATER LICENSE NO. 231 741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION - ` - DISTRICT NO. P OC SED BY
I hereby affirm that I am licensed under provisions Chapter GAS SYSTEM/STLETS
9•(commencin6 with Section 7000)of Division 3 of the Business OUTLETS OVER U
and Professions Code, and my license is in full force and ef- - 5 PER SYSTEM FINAL (.`q VALID I N Y
fect. DATE D /7 / 0
License Number- 231 741 Lic. Class C36-20-'- V
- .FIN,CD" /�h/rfi•i _ cc
Contractor Owen Bros-' P1 ltiDaie 1-9S-RQ BY O
.0 I am exempt under Sec. • ��,(.I.s ] �' W
5_x117 . QEF >_t d
B &P C:for this reason' T D Ly,i N
Plan check fee . r.1�;_{ll _
Date: s
' PLUMBING PERMIT ISSUING FEES jtlfrift 202 - 50
Signature
C jE t._ .,,
• _ - - TOTAL FE202._tl i
SINGLE FAMILY n r
_
HOME OWNER-BUILDER DECLARATION ,"1 -Plan check applicant - _ CHH!GE ,(•{t]
I hereby,affirm that I am exempt from the Contractor's License Name .r..
Low for the following reason (Section 7031.5, Business and
Professions Cade): _ Address - ` - IM [j GOO i 2/22/2"Y
❑ I, as owner of the property, will do the work.and the City .. Tel. No. + 1 'j - 1 Art it;;3?
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). - - -
iC CONSTRUCTION LENDING AGENCY -
I hereby.offirffi that there is a constructio0ending agency for -
the performance of the.work for which this permit is issued - - -
.(Sec. 3097, Civl C.).
Lender's Name
Lender's Address
certify that I have read this application and state that the - - -
a4ove information is correct. l agree to comply with all County n
Phmontes and State laws regulating Plumbing, and hereby -
uthorize representatives of this County to enter upon the '
be entioned property for inspection purposes. -
t
� 1-25-89 SEE REVERSE FOR EXPLANATORY LANGUAGE
. '
SIlglature of Permittee ' Date - r