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Home My Public Portal About5430 EL MONTE AVE_Plumbing__ rWORKER'SCOMPENSATION DECLARATION 76A666DPW9189 AP�L��L�il��®pll FOR, � ��n nr��pn� ��p�� 76A667A u��11f U u'�u u�f ud'u �J 14ereby affirm that I have a certificate of consent to self insure, ora certificate pf Worker's Compensation Insurance, or a certified copy't-hereof(Sec.3800 Lab.C.) 10-0489604. CNA'.Ins.' Co. COUNTY OF LOS ANGELES DEPT. OF rUBLIC-WORKS DEPT:OF PUBLIC WORKS'DIV. Policy No. Company Certified copy is hereby furnished. s -7FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING LJ' Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM Q FEE 5.-.5-92 (�wen Plumbing.Bros. LOCALITY .Temple City Date Applicant g 4 WATER CLOSET 4..55 58 .20 NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS''• CROSS ST. BATH TUB COMPENSATION INSURANCE -ASSESSOR BOOK PAGE" PARCEL (This section need not be completed if the work involved by the 1 SHOWER 14 55 MA permit is for one hundred dollars($100)or less.) OWNER I certify that in the,performance of the work for which this permit LAVATORY 72 75 D011 Me .er is issued, I shall not employ any person in any manner so as to SINK MAIL become subject toAhe Workers' Compensation Laws. 1 ADDRESS 1 DISWASHER 14 ,55' CITY` .Temple City TEL.NO. ,574-23:57 Date Applicant CLOTHES WASHER CONTRACTOR' NOTICE TO APPLICANT:'If, after making this Certificate of. OWen'.BrOS. Plumbing, .Inc. Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR 42'65- N; :Baldwin Avenue provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATIONCITY TEL.NO. I hereby affirm that I am licensed under provisions of'Chapter 9 WATER HEATER fl STATELIC. O (commencing with Section 7000) of Division 3 of the Business and 1 GAS SYSTEM 7XX OUTLETS 22 21 LICENSE NO. 231. 1741 CLASS C36-20-16 U Professions Code, and my license is in full force and effect. OUTLETS OVER DISTRICT NO. PROCESSED BY a: 231 741 06--20-16 5 PER SYSTEM �0�i License Number Lia Class O 1 Bar sink W Owen .Bros. Plmb. FINAL _ VALIDATION DATE (L Contractor Date 5=5-92 " ° _ ri) ❑ —� I am exempt under Sec. FINAL ." "=t _ '"° B.&P.C.for this reason Date: Plan check fee PLUMBING PERMIT ISSUING FEE$ 4 Signature t"r` _ TOTAL FEE 323.141 SINGLE FAMILY Plan check applicant HOME OWNER-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 . Code): 7 2 EJ 1, Tel.No. w_. 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). i CONSTRUCTION LENDING AGENCY 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 a d State laws regulating Plumbing, and hereby authorize r enta s of this County to enter upon the above-mentioned _ p e ty r in pection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE og=ba -5-92 fodature-of Permittee Date WORKER'S COMPENSATION DECLARATION 20-0026 DPW PW 9189 APPUCAMN FOR PLUM IG PERNT I•hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING r�••?Oj D� G ❑ Certified copy is filed with the county building inspection ADDRESS J -/ C, department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY • CC Date Applicant WATER CLOSET S� NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. J' COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) OWNER J� I certify that in the performance of the work for which this permit LAVATORY ' -(� D�6 �Q is issued, I shall not employ any person in any manner so as toSINK MAIL ESS�u�a become subject to the Workers'Compensation Laws. DISWASHER CITY ��.f- TEL.NOS7S-7 Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR G(//✓ IFZ WO"Z-7 Exemption,you should•become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. `��/ LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER- n. (commencing with Section 7000) of Division 3 of the Business and STATE LIC. LICENSE NO. CLASS O Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS V OUTLETS OVER ` DISTRICT NO.f! Cis PROCESSED BY o 5 PER SYSTEM (�C" License Number Lic.Class FINAL VALIDATION a Contractor Date DATE n (n ❑ - FINAL /,� Z I am exempt under Sec. O BY !�/.✓- B.&P.C.for this reason ' Plan check fee Date: Signature PLUMBING PERMIT ISSUING FEE$ 7S Ell TOTAL FEE s SINGLE FAMILY Plan check applicant r '- -. -. HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law t1'.�•1 a4 t for the following reason (Section 7031.5, Business and Professions Address "' 3!7 11�o0 5 - City Tel. No. 1 ITEMS , as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business TOTAL - 112 o C115/ and Professions Code). .( 4 ��'� ll�+y _ i{ CONSTRUCTION LENDING AGENCY is�ri 00-pehereby affirm that there is a construction lending agency for the C _00- performance rformance of the work for which this permit is issued (Sec. 3097, _.. Civ.C.) Lender's Name 4 -0001 �9to�ti�3/92 Lender's Address i 5346 1 A `1V o05 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 rep ativ of this County to enter upon the above-mentioned p operty f r' pn o s. - SEE REVERSE FOR EXPLANATORY LANGUAGE Sig Lure of Permittee Date