HomeMy Public PortalAbout10750 GRAND AVE_Plumbing__ WORKUr COMPENSATION DI=CLARATION APPLICATION FOR PLUMBING PERMIT
„_..1 her'bby afflrm that I have a carttfiGatp of consent to self 76A667A
a
neuro, or certificate of Workers' Cornpeasatlon Insurance, C> 817(REV, 10/81)
4011 - filed copy thereof (Sec 9800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFM
Policy No, PC 97ri�9_'j2mpany RPRi ITC_ 113den-lnity
Certffled copy is hereby furnished..
FOR APPLICANT TO RLL IN(PRINT OR TYPE) BUfLDING r
F1 Cerilfledcopyls fired with Ing I ADDRESS 10750 Fast ('.C;lnd A=ue
tion department. NUMBER P1XTl1RE OR rrEM Q F�E
LOCJ11FfY Temple City
¢ate 11/98/ RR ApplIgant WATERCLQSET NEAREST
CERTIFICATE OF EXEMPTION R20Ah WORU_RS`
BATHTUB aRc�S ST. 5anta An Ita
0QMPR4SATIQN INSURANCESOWNER
(This seri " 6a"
not be r ortw4ited tf the work Imrohrr.d by FtOWER
the Pernik is h)r orae hundred dollars(:100)or lona LAVATORY MAIL
ADDRESS A ue
I certify that In the performance of the work for which this ,1 1 144 ^1
permit Is Issued,I shall not emproy am
ny person In any manner SIMC crFY Teple City TEL No.4 -1462
so as to beepme subfect to the WorketV Compensation Laws.
DISFIWASNER
cowRAcrgryant Heating and Air Condition! Inc.
Data 11/28/89 Applicant ArVant H19,& AIC ^ cLoTmES WASHER
NOTICE TO APPLICANT: If, after making this Certtfltote of AbDRESS ?3�0 E. Tunas Drive
Exempflorr, you should become subject to the Workers'
SWIM,NCPOOL RECEPTOR CITY San Gabriel TEL No. 2$6-114
Compensation provisions of rho-Labor Code, you most forth, LAWN SPRINKLER SYSTEM
with comply with such provisions oc tbis.permit shall be SFA UC,
deemed revoked. WATER HEATER pgatsE NO. 221751 CLASS G-20
'LICENSED CONTRACTORS DECLARATION DISTRIKdj<
BY
1 hereby afffrm that I am Ilcensed udder provislons of Chbpter 9 GAS SYSTEM OUTLETS
(commencing with Sectlon 7060)of DlvltloR 3 of the Business
OVER
anderofenior*Ccie,and my license is In foil ford and effect. S PER SYSTEM FINAL V LI ON ,
Llcen N Ic. ClaisC^7(l DATE
fl V9
Co ctor Date 11/7f3/Rf3 BX O
C
I am exempt under Sec._, ,r^,
$.&P.C. for tbls rpaspn PIgr1 check fee
Ddte: . PLUMBING PERMIT ISSUING FES; —
Slgrwture ,r
TOTAL Fly
SINGLE FAMILY ck
Plein cheapplicant
FIOME OWNER-BUILDER DECLARATION Nome
)'hereby affirm that I am exempt from the Contractors Ucense Address 7.9 a
Low for the following repson (Section 7031.5, Buslness and
fprofessions Code): City Tel. No.
ro
i t # P o o a o 5
lJ 1, at owner of crib property, will do the work and the
structure It not Intended or offered-for sale (Sectloa ► )i ° . 1650
7644,BCo
uaInsit and Professions de)
CONSTRUCTION LENDING AGENCY 0'.0 016506
1 hetaffirm that them Is a construction lending agency for
the performance of the worst for whrch this permit is Iscsaed 1220-88
(Sec. 3097, Clv. C.).
Lender's Name- �T
Lender't_Ag}dress
I certify than I hove rood this application and state that thb ,
abgye Informgtlon Is correct, I agree 4o comply with all Cbvmy
ordlnancps and Stpte laws regulating-Plurnbinp, and hereby
Ize representatives of thlr.County to enter upon the
bbv Io opetty for InspectJon pu
/ SEE REVERE FOR EXPLANATORY LANGUAGE
na re of Itt