HomeMy Public PortalAbout6032 GOLDEN WEST AVE_Plumbing__ NRKER'SCOMPENSATIONDECLARATION 20.0026 DPW 9/89 APPLICATION FOR PLUMBING PERMIT
76A667A
I i'Pereby affirm that I have a certificate of consent to self insure, ,
or a-cgrtificate of Worker's Compensation Insurance, or a certified
copy`ihereof(Sec.3800 Lab. C.)
Many No.-l(}04F39Fi04 Company (7A M]RATTE M_ 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 6032 Golden West
Certified copy is filed with the county building inspection '
department. NUMBER FIXTURE bR ITEM @ FEE
LOCALITY T
mple City
Date 1-2-91 Applicant Owen Bkos. Plumb. WATER CLOSET
50 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
3 BATH TUB � 22 50 ,
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the 1 ISHOWER 7 50 MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) r5 LAVATORY 37 50 OWNER EIjDIE IP CONSTRUCTION
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as toMAIL
become subject to the Workers'Compensation Laws. 2 SINK / Bar sink 15 100 ADDRESS 250 W. Camino Real
1 DISWASHER 7 50 CITY TELArradia .NO.
446-55-3
Date Applicant 1 CLOTHES WASHER 7. 50
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Owen Bros. Plumbing. Inc.
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code, you must forthwith comply with such 4265 N.' Baldwin Avenue
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO. Y
I hereby affirm that I am licensed under provisions of Chapter 9 1 WATER HEATER 7 50 El Monte 443-0078 a.
(commencing with Section 7000) of Division 3 of the Business and STATE LIC.
Professions Code,and my license is in full force and effect. 1 GAS SYSTEM r5 OUTLETS 7 50 LICENSE NO. 23 CLASSC36-29-16 (�
OUTLETS OVER DISTRICT NO. PROCESSED BY a:
i 5 PER SYSTEM
License Number 231 741 Li..Class C36-20-16 ®
FINAL )) LV
/_�S ,.C� �� VALIDATION
Contractor Olden Bros, Plumb Date 1-2-91 DATE a-
I��JJ U)
❑ FINAL Z
I am exempt under Sec. BY
B.&P.C.for this reason
Date: Plan check fee ,
Signature PLUMBING PERMIT ISSUING FEE$ 13 00
❑ TOTAL FEE 148 00
Plan check applicant 5
SINGLE FAMILY ,•i, a
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 I.Address
Code):
❑ - k :.(-�E'�="
I, as owner of the property,will do the work and the structure City Tel. No. a
is not intended or offered for sale (Section 7044, Business 1 t-i'11L 143 � '�-•0
and Professions Code). ► ¢ t' --
CONSTRUCTION LENDING AGENCYi
I hereby affirm that there is a construction lending agency for the f_'. iAN`G1_
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 com ly with all County ordinances
and State/laws r lating Plum i g, and hereby authorize --
prese tiv s s County to upo the above-mentioned
for ns n purpose SEE REVERSE FOR EXPLANATORY LANGUAGE
-91
nature of Permitt Date