HomeMy Public PortalAbout6036 GOLDEN WEST AVE_Plumbing__ • WPRKER'SCOMPENSATIONDECLARATION 20-0026 DPW 9189 APPLICATION FOR PLUMBING PERMIT
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I hereby affirm that'I have a certificate of consent to self insure,
or&cp�Y ificate of Worker's Compensation Insuranc�r, or a certified
copyFhereof(Sec.3800 Lab.C.)
Policy No. Company 10-0489604 CM Il�.��� OJ. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT, OF PUBLIC WORKS DIV.
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❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
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L13 Certified copy is filed with the county building inspection ADDRESS 60 Golden West
department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY Temple Cit
Date 1-2-91 Applicant Owen Bros. Plumb• 3 50 WATER CLOSET NEAREST
22
CERTIFICATE OF EXEMPTION FROM WORKERS' 3 BATH TUB 22 CROSS ST.
5O ASSESSOR
COMPENSATION INSURANCE MAP BOOK PAGE PARCEL
(This section need not be completed if the work involved by the 1 SHOWER '7 50
permit is for one hundred dollars($100)Or less.) 5 LAVATORY 37 50 °WNER EODIE IP"'CONSTRUCTION
I certify that in the performance of the work for which this permit
MAIL
is issued, I shall not employ any person in any manner so as to SINK ADDRESS
become subject to the Workers' Compensation Laws. 2 Bar Sink 15 00 250 W. Camino Real
1 DISWASHER 7 50 CITY Arcadia TEL.NO. 446-5537
Date Applicant CLOTHES WASHER 7 50
NOTICE-TO APPLICANT: If, after making this Certificate of CONTRACTOR Owen Bros. Plumbing
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS
4265 N_ Baldwin Aypnuc-
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO. }
I hereby affirm that I am licensed under provisions of Chapter 9 1 WATER HEATER 7 50 STATE LIC.
El Monte 443-0078
(commencing with Section 7000) of Division 3 of the Business and LICENSE.NO. C ASS
Professions Code,and my license is in full force and effect. 1 GAS SYSTEM rj OUTLETS 7 50 231 741 C36-20-16 U
OUTLETS OVER DISTRICT NO. PROCESSED BY It
5 PER SYSTEM
License Number 231 741 Lic.Class C36-20-16 � �� -�' �
FINAL VALIDATION Rio
Owen Bros. Plumb 1-2-91 DATE Z0.
Contractor Date do
AL Z
❑ I am exempt under Sec. By
B.&P.C.for this reason
Plan check fee ,
Date:
Signature PLUMBING PERMIT ISSUING FEE$ 3 00
❑ TOTAL FEE 148 00
SINGLE FAMILY Plan check applicant
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HOME OWNER-BUILDER DECLARATION Name `«' I =
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): ,L'•r
❑ � i;' �__
I, as owner of the property,will do the work and the structure City Tel. No. ,• q „
is not intended or offered for sale (Section 7044, Business '-j i HL -� m 00-11k
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
Hl; .. +..
Lender's Address
I certify that I have read this application and state that the above ,
info rmati n is correct. I agree to comply with all County ordinancles
and ate�I s regulating mbing, and hereby authorize
r entat' f this C t o �ter upon the above-mentioned
P er f ection pur s s. SEE REVERSE FOR EXPLANATORY LANGUAGE
1-2-91
nature of PernOi ee Date