HomeMy Public PortalAbout5616 GOLDEN WEST AVE_Plumbing__ • WORKER'S COMPENSATION
certificate
of consent to 76A666DPW 9/89 APPLICATION FOR PLUMBING PERMIT
76A667A
I h�reby.affim that a have a certificate of consent to self insure,
or a certifibate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.)
Policy No. 994965 Company Republic Indemnity COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 5616 N. GOLDENWEST
L� Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM @ FEE
.b. LOCALITY TEMPLE CITY, CA
Date 6/24/93 Applican � WATER CLOSET vv NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB / V CROSS ASSESSOR
OR
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE 4010 PARCEL
permit is for one hundred dollars($100)or less.) 2 LAVATORY OWNER JOE CAMPIONE
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as toMAIL
SINK
become subject to the Workers' Compensation Laws. ADDRESS 5603 N. GOLDENWEST
DISWASHER 67 CITY TEMPLE CITY TEL.NO.285-8823
Date Applicant CLOTHES WASHER M'
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR P,RANK NARRONE & SONS INC.
Exemption,you should become subject to the Workers' Compensation SWIMMING POOL RECEPTOR ADDRESS 9860 LOWER AZUSA ROAD
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked. . LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY EL MONTE TEL.NO.444-2548 }
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
(commencing with Section 7000) of Division 3 of the Business andSTATE LIC.
Professions Code, and my license is in full force and effect. GAS SYSTEM OUTLETS 9LICENSE NO. 397884 CLASS C/36 C/16
OUTLETS OVER 6 DISTRICT NO. PROCESSED BY a:02 5 PER SYSTEM
License Number Q f/ o
397884 C/36 C/16
Lic.Class
FINALc W
F. Marrone & Sons VALIDATION Inc. 12/31/93 DATE �Z_/7•/3 (L
Contractor Date (0
❑ I am exempt under Sec. BY AL
B.&P.C.for this reason
Plan check fee '
Date:
Signature PLUMBING PERMIT ISSUING FEE$
❑ TOTAL FEE 414—
c
Plan check applicant 't
SINGLE FAMILY i'Ii_�t CCT n a
HOME OWNER-BUILDER DECLARATION Name
hereby affirm that I am exempt from the Contractor's License Law1�) V c4e
for the following reason (Section 7031.5, Business and Professions Address i ITEMS
Code): 1
❑ City Tel. No. °• -
I,as owner of the property,will do the work and the structure TOTAL 281S, 45
is not intended or offered for sale (Section 7044, Business LLtl
and Professions Code). ► CHECK z=�=a 45
CONSTRUCTION LENDING AGENCY CHANGE _00
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.) '01,10—f 13131 2/ 9/93
Lender's Name 8115 I AM 11:27
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 e r upon the above-mentioned
prop ty for inspection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature Permittee to