HomeMy Public PortalAbout4939 DOREEN AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 20-00 6 PW 9189 p - s
.'I hereby afficm that I have a certificate of consent 6
to self insure, APPLICATION FOR PLUMBING PERMIT u
or a cbrtificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Cali. C.1
10-0489604 CNA'. Ins. Co. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS 'DEPT. OF PUBLIC WORKS DIV.
Policy No. Company
Certified copy is hereby furnished. _
r FOR.APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection 4939 DnrPEn
ADDRESS
department. NUMBER FIXTURE OR ITEM (,n FEE
2-3-92 Owen .Bros: `Plumbin CROSSLOCALITemple City
Date Applicant g WATERCLOSET 5l) S NEAREST
F15 CROSS ST.
_ CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB -
COMPENSATIONINSURANCEASSESSOR
(This section need not be.completed if the work involved by the r SHOWER '^ MAP BOOK PAGE PARCEL,
permit is for one'.hundred dollars($100)or less) L/ OWNER a -r -
I certify that in the performance of the work for whichzthis permit LAVATORY 'a J4 '.
is issued, I shall not employ any'person in any manner so as to _I ,SINK - Z MAIL 115 La"Porte .Street
become subject to the Workers'Compensation Laws. [—
J ADDRESS
i' DISWASHER _44J'S CITY Arcadia TEL-NO. 574-7355 .
Date Applicant CLOTHES WASHER CONTRACTOR'
NOTICE TO APPLICANT: If,. after making this Certificate of . :Owen .Bros.-Plumbing, Inc.
Exemption, you should become subject'.to the Workers' Compensation SWIMMING POOL RECEPTOR 4265 N. .BaldWln Avenue
provisions of the Labor Cade, you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked. - LAWN SPRINKLER SYSTEM 443-0078
LICENSED CONTRACTORS DECLARATION CITY TEL.NO.
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER - L 5 d
(commencing with Section 7000) of Division 3 of the Business and STATE 23LIC. O
1 741
Professions Code, and my license is in full farce and effect. GAS SYSTEM _ OUTLETS �S LICENSE NO. CLASS C36-20-16
OUTLETS OVER DISTRICT NO. PROCESSED BY
231 741 C36-20-16 5 PER sysrEM - O
License Number Lic.Class ( z
FINAL VALIDATION
Owen Bros. Plmb. 2-3-92 ( n DATE 9_� �� a
Contractor Date rn
❑ I am exempt under Sec. FINBY ALZA
Z
B.BP.C.for this reason r�
Date:
Plan check fee D
^ _ - -
Signature PLUMBING PERMIT ISSUING FEE$ S
❑ TOTAL FEE 0 / +
SINGLE FAMILY Plan check applicant =
HOMEOWNER-BUILDER DECLARATION 'Name"
I hereby affirm that I am exempt from the Contractor's License Law .
for the following reason (Section 7031.5, Business and Professions Address .. _ - ^vj•I I vl'1
Code): -
❑ City Tel. No. - T`!i_It[
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). ,) + D L^+
CONSTRUCTION LENDING AGENCY - + - -- - t `IP t"_L1
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
1 certify that I have read this application and slate that the above - - -- - D -
in is correct. I agree to comply with all County ordinances
and State laws regulating Plumbing, and hereby authorize -
r ppnatu"rve
.this Ccan��a enter upon the above-mentioned t
pcoon p r G•0 - SEE REVERSE FOR EXPLANATORY LANGUAGE
f 3
S Per tee Date