HomeMy Public PortalAbout9324 LOWER AZUSA RD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �-t
I_hefeb , 0'firm thaY I have o'certificate of consent to self in- 76A666 DPW 4/87
• �76A667A
Sore,ora certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86)
cert+fled copy thereof(Sec. 3800, I.A. C.) COUNTY OF LOS.ANGELES DEPT. OF PUBLIC WORKS'a
Policy NP-1 f1-0d8gj6 14Company CM Tn- ' C'Q- 5 ACertified'i�opy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the c..ounty building inspection ADDRESS
department: NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple City .
Date 6-21-91 —Applicant.Qkan Tim.-_ Plmh WATER CLOSET(TOILET] , NEAREST ,
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OWNER.,. . .OWP11 DeV�].Opment•
(This section need not be completed if the work involved by MAIL 2031 S. 1��le A�lenue
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
1 certify that in the,performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so �/ CITY TEL:NO.• —
as to'become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR OWen BrOS.. PjUjjb]nq
Date Applicant CLOTHES WASHER 'ADDRESS ' 4265 N
• BaldWin AVelMe
NOTICE TO APPLICANT: If, after making this Certificafe of Ex- SWIMMING POOCRECEPTOR
errfption;you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp= LAWN SPRINKLER SYSTEM El Monte 443 0 8
eydwith such provisions or this permit shall be deemed revok- ,^ STATE 231 •741 LIC. C-36-2b-16
WATER HEATER w 3o LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions-of Chapter GAS SYSTEM ! OUTLETS
0 CiY�d�- ^✓
9(commencing with Section 7000)of Division 3 of the Business-, OUTLETS OVER
and Professions Code, and my license is in fu.11 force and,ef- 5 PER SYSTEM FINAL VALIDATION D'
fect" DATE l_ jq_ O
License Number •'7O1 X41 Lic. Class G��—'��—�c O� V
��••����.,,�� T �� FINAL
Contractopi Bros. 'P13pb Date' 6-21-91 BY O
�. 1 dm exempt under Sec.. ULU
CL
B.&P.C. for this reason ® U)• Plan check fee �
Date: PLUMBING PERMIT ISSUING FEE$
Signature TOTAL.FEE
SINGLE FAMILY Plan check o
;HOME OWNER=BUILDER DECLARATION. Pplicant
I hereby affirm that I am exempt from the Contractor's License Name .0
Law for the following reason (Section 7031 .5,-Business'andY- os
Professions Code): Address AC
El1,.as owner of the property, will do the work and the City Tel. No. Ovl 1,610.70structure is not intended or offered for sale(Section 7044, 1 F T EMS
Business and Professions Code). ► TOTAL 160® 70
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constru;tion lending agency for CHECK 160.701
the performance of the work for which this permit is issued CHANGE �I_Il
(Sec. 3097, Civ. C..).
.Lender's Name
Lender's Address
1 certify that I have read this application and state that the, �' "{� ' t
above information is correct. I agree to comply with all County ,
ordinances and State laws regulating Plumbing, and hereby
uthorize representatives of this County to enter upon the
bove-mentioned property for inspection purposes.
6-21-91 SEE REVERSE FOR EXPLANATORY LANGUAGE
VknolunVo—fPermitiee Date