HomeMy Public PortalAbout10121 GREEN ST_Plumbing__ ' WORKERS'COMPENSATION DECLARATION
I-h4l eaW affirm- t}tat I-have a ce lflt4 of consent to self 20-dG26 pPW 6/B7 APPLICATION FOR PLUMBING PERMIT
,In�u e, of a certtficate of Worker' Compensation Insurance, 76A667A
} ,o*a certffled copy thereof (Sec. 3800, Lab. C.) C�11NTY OF LOS ANGELES DEPT. OF PUBLIC WORKS. u
Policy No)0-04896Q4rmpany CNA Ina, Co.
0.
Certified copy Is hereby fumished.
FOR APPUGANT TO AU.IN(PRINT OR TYPE) BUILdINC'
Certified
fled ctrryi ^filed with the county building Inspec- Q 101 2 1 Green St.
Q NUMBED! RM RE-OR ITEM FEE
1 LOCAL"
Temple City
Date -1-0n Appllgant 1a
WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
KW
COMPU4SATION INSURANCE SHOWS OWNE3t 1 r
these e*ctl h for M hundred dollen 100)or I LAVATORY
te+a+� N ) �s 2035 S. Myrtle Ave.
I certify,that In the performance of the work for which this
permit It Imupd, I shall not employ any Person In any manner VNX crry nrovl& Ca Ta- N9959-K I I
so cm to become subject to the Worker Compensation Laws. DISHWASHER
COtJ TRACT
DateApplicant CLOTHES WASHER ADDRESS
NOTICE JOI APPLICANT: If, often making this Certificate of d 4265 N. BaldWin Ayp.
Exemption you should become subject to the Workers' C[T E1 Monte TB- NO+43-0078
Compensation Provisions of the Labor trode, you must forth- LA"SPRINKLER SYSTEM
with corrlply with such provltlons or this permlt shall be 57ATE
deemed revoked. WATER HEATER LICENSE No. 231-741 aAss oil
LICENSED CONTRACTORS DECLARATION) GAS SYSTEM OUTLETS
NO BY
I hereby afflmi-thot I am licensed under provisions of Chapter 9
( }mopcing with SecHoa 7000) of Dlwlsipn 3 of the Bwlness OUTLETS OVER
clad Nvfesslgm Code,and my Iltepse Is In full force and effect. .5-PER SYSM IDA
ALIDATIONTJcerneNumber 231-741 f�Ic. ClassG36AZOAL
Corittodoc�Wen Bros. Plam>x ¢ 9-30-91
1 am-exempt under Sec.
B.✓I,P.C. for this reason PIQn check fee
D60 to PLUMBING PERMIT ISSUING lam;
Signature
TOTAL FEE
SINGLE FAM1tY
Plan check applicant ` r
--- '
HOMEOWNER-BUILDER DECLARATION) Name ; AGCT.0
I heribytifflrm that I am exempt from the Contractor's License
Law fpr the following reason (Section 7031.5, Business and 'sffess ` 3347 112.50
Professions Code): City Tel. No. i I'I'
I, a, owner of the property,will do the Work and the i
strAtcture Is not Intended or offered fall sale (SectionTOTAL 112.50
70441 Businem and Profenions Code). T� CKCK 1 J2■r50
CONSTRUCTION LENDING AG8NCY _ 00
ta
I hql affirm that theis a construction lending agency for '
the,perf6rmance of the'work for which this permit 11.issued
(Sec.3097, Clv. C.)
0000--0001 11J ]./$�'
LendeN Name 1 17110:n
Lenders Address
I certtfy that 1 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
au onus reorelenfatives of this County to enter upon the
vo- o led' r Inspection purposes.
SEE kEViRtE FOR EXPLANATORY LANGUAGE
—IDA
Igrtature of Per-mittDate
r
' WORKERS'.CjJAAPENSaTION D ,nqN APPLICATION FOR PLUMBING PERMIT
( l ha4by,afflrm that I have o ceritflcate of consent to seff '20-0026 DPW 6/137
Insure, or a certificate of Worker' Compentatlon Insurance, 76AB67A
or a certlfled copy thereof (sec. 38Q0, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No.10-0489.60&ompany CNA Ins. Co..
Certffied copy Is hereby fumished.
® Certified copy is filed with The county building Irtspec- FQR APPLICANT TO RLL IN(PRINT OR TYRE) ADDR NG
ADDRESS 10121 Green St.
tlon department. NUMaER RM RE ORi1EM p FEE
LOCf�LiX
V
Date 1-1-00 A{ppllont Oweia Bros. Plmb WATtRLOCAft
CLOSEr NEAREST
CERTIFICATE OF EXEMMON FROM WORKERS' BATH TUB - CROSS ST.
COMPENSATION INSURANCE SHOWER OWE . Owen Development
(Tfib section nand not be completed If the work Imrolved by MAJL
tho.p6irmlt rs for one hyndred dollars($100)or IKr.) LAVAtORY ,CORS 20 S. Myrtle Ave.
I Certify that In the performance of the work for which this
permlt Is Issued, I shall not employ any perwn In any maoner IdNDCTfY arQvi TEL NO. _
so m to become subject to the Worker Compensation Laws. DLSFIWASHER
COWk^CToROwea Bros. Plumbing, Inc
Date - Appllcpnt CLOP-ES WAS-ER
If,TO APPLICA.W: , after ;.Ting this Certificate of A RECEPTOR 4265 N. Baldwin Ave.
Exemption, you thould become subject to the Wbrkers' SWIMMING PboL
Compensatlon provisions of the Labor Code, you must forth- LAWN SPRit�cLERbYSrEM
CITY E1 Monte TEL No. 443-0078
with comply with such provisions or ,this permit shall be STATE 231-74 1 UC'deemed deemed revoked. WATEkHEATT3t LICam NO CLASS
LICENSED CONTRACTORS DECLARATION D CT NO. PROCESSW BY
I lzereby affirm that I am licensed under provlslors of ChQpter 9 GAS SYSTW OUTLETS
(comm n log wffh Section 7000) of Dlvlslon 3 of the Busmen OUTLETS OVER '
and Profeeslorn Code,and my license is M full force and effect. 5 PER SSM FINIAL
Llcerrse Number 231-741 plc. claa C36-20 .
DATE ALJDATION ,
FINAL
Contractor Owen Bros. Date 9-30-9 1 BY
tam exempt under Sac.
B.BP.C. for this reason
Plan check fee
Thr PLUMBING PERMIT ISSUING FEE; *+
Signaturet
TOTALFEE
Plan check applicant 5
SINGLE FAMILY
NOW OWNER-BUILDER that iS�CLARATION Name AULT■i
I hereby affirm at J am exempt from the Contractor's Llcense Address A�•r y�
Law for the following reason (Section 7031.5, Business and 33 07 iii. 0
Professions Code): City Tal. No. 1 IT
QI, as owner of the property, will do the work and the
struMrs Is not Intended or offered for sale (Section ' TOTAL 16 - 50
70", Business and Professlong Code).
CONSTRUCTION LENDING AGENCY CWCK M.50
I hereby affirm that there Is a construction lending agency for .00
the performance of the work for which this permit Is Issued
(Sec. 3097, Cly. C.).
Lendert Name- M-M101 12/29/$9
Lender's Addrew
1 AM 9:21
1 certify that'l have read this application and state that the ►
above Information Is cortect. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize repretentatives of this County to enter upon the,
above-mentloned'property for Inspectlon purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
X"g- r rmlttee Date