HomeMy Public PortalAbout9614 BROADWAY_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or 6 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. PC'94367�ompany Republic Indemnity
❑
Certified copy is hereby furnished. BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 9614 Broadway
Cornified copy is filed with the county buildin inspec-
' tion department. � NUMBER FI%TURF OR ITEM @ FEE LOCALITY
Date 8/23/93 Applicant {, Joo�1 L WATER CLOSET NEAREST Terap
CERTIFICATE OF EXEMPTION FROM WORKER ' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER Mr. & Mrs. Ronald Kline
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS 9614 Broadway
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITYTpmpltaCity TEL. NO. 309-9111
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Bryant Heating & A/C, Inc
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- San GAbriel 286
LAWN SPRINKLER SYSTEM -1141
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. Cass C-20
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
hereby off irmthat I am licensed under provisions of Chapter 9 1 GAS SYSTEM OUTLETS 5' �D�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER _ }
and Professions Code,and my license is in full force and effect, 5 PER SYSTEM FINAL ATION (y
n i
221751 G-20 DATE L3 O:
License Number Lic. Class FINAL Jdl)J 41.CJ U'
Contractor .,/ Dote 8/23/93 By 1 ITEM,AL
❑ I am exempt under Sec. TOTAL 4 1 - 835 VI
is•—°W
B.BP.C. for this reason ¢O.f
Plan check fee � CHECK 41.`tea m
Date: PLUMBING PERMIT ISSUING FEE$ t_Hfi1J6E Z
Signature
TOTAL FEE
Plan check applicant 0000—OOC11 5124/5",
SINGLE
5•r124/`"SINGLE FAMILY 1414 1 {all 4;14
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
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
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
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 laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned pr rerty for spection purposes.
A Z/ SEE REVERSE FOR EXPLANATORY LANGUAGE
ft C j-- /fes . 8/23/93
Signature of Permittee Date