HomeMy Public PortalAbout5734 KAUFFMAN AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
d,I ,e ut5y:gffirm that I have a certificate of consent to'self 20-0026 DPW 6/87
-insure,-or a certificate of Workers' Compensation Insurance, 76A667A IL JI
or,a certified copy thereof (Sec. 3800, Lab. C. ^ COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No 10-9489604 Company CNA Ins. Co.
❑ ,Certified copy is hereby furnished.
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy,is filed with the county building inspec- ADDRESS, 5734 Kauffman
tion deportment. NUMBER FIXTURE OR ITEM Q FEE LOCALITY
WATER CLOSET Temple -Cit-y
Date 1-1-90 MnAppliganl BIOS. PlUiilbin7 NEAREST I •
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB -CROSS ST
COMPENSATION INSURANCE OWNER Owen Develo ment
(This section need not be completed if the work involved by SHOWER MAIL
the permit is for one hundred dollars (6100)or less.) LAVATORY ADDRESS 2035' S. Myrtle Ave.
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITYMon ;TEL NO 359-3211
CONTRACTOR so as to become subject to the Workers'Compensation Laws. DISHWASHER '
Owen,, Brbs. ,Plumbing, Inc.
Date Applicant CLOTHES WASHER ADDRESS '
NOTICE TO APPLICANT: If, after making this Certificate of N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY E1 Monte TEL: NO 443-0078
Compensation•provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE 231_741 LIC C36-20
deemed revoked. WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION . DISTRICT NO. PRESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS . (.
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER v
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
VALIDATION
DATE
License Number 911-7141 Lic Class C36-20 U
FIN
Contractor Owen Bros. PIU ITbingpate 9-30-89 BY 0,
❑ I am exempt under Sec. 0
IIAF
B.BP.C. for this reason
Plan check fee ® U)
Date: PLUMBING PERMIT ISSUING FEE'$
Signature
TOTAL FEE
.SINGLE FAMILY
Plan check applicant
HOME OWNER-BUILDER DECLARATION Name -
I hereby'affirm tkat I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and -- z 112.50
Professions Code). City Tel. No. _ 71
❑ j, as owner of the property, will do the work and the T
structure is not intended or offered for sale (Section ® 7,_ �°- _ '—�,•< >=
7044, Business and Professions Code). —
CONSTRUCTION LENDING AGENCY �.�'� ` 1 L�,.5-1
I hereby affirm that there is a construction lending agency for _•..s.;__
the performance of the work for which this permit is issued =00
(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 comply with all County
ordinances-and State jaws regulating Plumbing, and hereby
authorize reprelentatives of this County to enter upon the
ove- a boned' rop for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
\c - 3-13-89
Signature of PermWee Date ;