HomeMy Public PortalAbout9518 LIVE OAK AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9/89 {�
76A667A Ll
I hereby affirm that I have a certificate of consent to self insure, APPLICATION FOR PLUMBING-PERMIT
or a certificate of'Worker's Compensation Insurance, or a certified
dopy theredf(Sec.3800 Lab. C.)
10-0489604 CNA Ins. Co. COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No. Company
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS 9518
Live Oak Avenue
department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY Temple City
Date 9-91-92 Applicant OWen .BYOB. Plumbing 5 WATER CLOSET 14.5 72 75 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. ,
BATH TUB 5& 20
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the I SHOWER 14 5 5 MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) 6 LAVATORY 87 O OWNER Tim Marshall
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to 1 SINKMAIL
1[� 5 ADDRESS
become subject to the Workers' Compensation Laws.
1 DISWASHER 14 55 CITY .Arcadia TEL.NO..355-8569
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of .14 55 CONTRACTOR Owen Bros. Plumbing, .Inc.
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR 4265 N. Baldwin Avenue
provisions of the Labor Code, you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM4+1143-0078
LICENSED CONTRACTORS DECLARATION CITY TEL.NO.
I hereby affirm that I am licensed under provisions of Chapter 9 1 WATER HEATER 14 55 CL
STATE(commencing with Section 7000) of Division 3 of the Business and LICENSE NO. 231 741 LIC.
G36-20—"1 6
Professions Code,and my license is in full force and effect. 1 GAS SYSTEM 7 OUTLETS 22 1. U
OUTLETS OVER DISTRICT NO. PR02ESaED BY a:
231 741 C36-20-16 5 PER SYSTEM r, Q
License Number Lic.Class 3 Hose bibbs 43 5 //�� 11, V
FINAL VALIDATION
Owen .Bros. Plmb. 1 Veg. sink 14 5 DATE 11_ a
Contractor Date 2721-92 / 7
❑ I am exempt under Sec. 1 Laundrya FINAL Z
BY
1 Bidet 14 55 4.
B.&P.C.for this reason
Plan check fee
Date: r
Signature
PLUMBING PERMIT ISSUING FEE$
❑ TOTAL FEE 425 6 :'_11 .....
Plan check applicant - :�•-
SINGLE FAMILY _
HOME OWNER-BUILDER DECLARATION Name .i =•{ _ i.l
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): _
City Tel. No. is":!''=^ :'s�" ''••
I, of the properly,will do the work and the structure
•, c e
is nded or offered for sale (Section 7044, Business _ ,_ i � ± •,
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
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 laws regulating Plumbing, and hereby authorize
re esentatives of this County to enter upon the above-mentioned
perty f r inspection purposes. 2-21-92 SEE REVERSE FOR EXPLANATORY LANGUAGE
nature 6f Permittee Date