HomeMy Public PortalAbout9940 LA ROSA DR_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
-;'iereky, affirm that I hcve a certificate bf consent to self in- 76A667ADPW a/87 n
sure,•or a certif:rate of W.brkers'Compensation Insurance,or a CE 817(REV. 8/86) ,ILlll
certified,copy thereof (Sec. 3800; Lab. C.)
•Pal;cy N,10-048960 Company CNA Ins. Co. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
® Certified copy is filed with the county building inspection ADDRESS 9940 La Rosa Dr.
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Temple City
Date 5-3-88 Applicant Owen Bros. Plba. WATER CLOSET(TOILET) e NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER D&G Const .
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY — ADDRESS 11670 Lambert Ave.
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY E1 Monte TEL. No 350-6859
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR Owen Bros. Plumbing, Inc.
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS
4265 N_ Rnldwin Ave.
emption,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR
saiion provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM CITY E1 Monte TEL N0443-0078
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. 231 741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR BSSED BY
I hereby affirm that I am licensed under provisions of Chapter
GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
fed Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VA DATION y
DATE 0
License Number 231 741 Lic. Class C.16-2O U
FIN � Q
Contractor Owen Pl h
Rrnc �_ o_Date 5-9-88 BY O
I am exempt under Sec. - W
fl
B.BP.C. for this reason ►fq 5 �,4 p =
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature 5
TOTAL FEE
SINGLE FAMILY ( • • 2 a 5 Q
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and • a . 2a5
Professions Code): Address 0
F] 1, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code).
05,098
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
Lender's Address
I certify that I hove 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
Vbe-me
ze re r sentative of is County to enter upon the
d propel f spectianpurposes.
5-3-88 SEE REVERSE FOR EXPLANATORY LANGUAGE
re of Permittee Dote