HomeMy Public PortalAbout5416 A & B MCCULLOCH AVE_Plumbing__ WORKERS'COMPENSA i ION DECLARATION,r . . 76A$67A
I hereby affirm that I have a' certificata of consent to self eE er7(z-a0)' APPLICATION FOR PLUMBING PERMIT
insum,or a crr0ficate of Workers'Compensation Insurance,or
a certified t:opy thereof(Sec.3800,Lab.C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No�f'�O�►�?7Company Aetna IngUgTver
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS 5416 A&B N. McCulloch Ave.
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE
department. LOCALITY
WATER CLOSET ' Tem le City
Date •8—ti—Rn Applicant..Qlr+en Rrne Plh�TnC. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 00 CROSS ST.
COMPENSATION INSURANCE SHOWER O OWNER Sharon 0. Lee
LAVATORY MAIL >_(This section need not be completed if the work involved 19 ADDRESS 4265 N. Baldwin Ave. n-
by the permit is for one hundred dollars ($100) or less.) SINK
CITY E1 Monte TEL.N0.443-0078 U
I certify that in the performance of the work for which this DISHWASHERT tr
permit is issued, I shall not employ any person in any manner D CONTRACTOR Owen Bros. PluMbing, Inc. p
so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER loo ~
Date Applicant ADDRESS 4265 N. Baldwin Ave. W
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR CITY El Monte TEL.NO.443-0078 coil
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC.
Compensation provisions of the Labor Code, you must forth- /� WATER HEATER LICENSE NO. 231741 CLASS C36-20
with comply with such provisions or this permit shall be oC
deemed revoked. GAS SYSTEM OUTLETS DIS�TRRICT N . P CESSED Y
LICENSED CONTRACTORS DECLARATION OUTLETS OVER `7 Ot
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL y� j VALIDATION
ness and Professions.Code, and my license is in full force and DATE
effect.
231741 C36-20 FINAL
License Number Lic.Class BY �-�
contractor Own ro _ Plumilibi ng, Tnc_ 8-6-80
F1 I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE I Won
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address J F.
License Law for the following reason (Section 7031.5, Busi- City Tel.No. 0 0 0 0 0
ness and Professions Code):
I, as owner of the property, am exclusively contracting 2 0 0 9 1.
with licensed contractors to construct the project
(Section 7044,Business and Professions Code). o c C. C 1 !,C.= _
CONSTRUCTION LENDING AGENCY C n. 1
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
e nti ed property nspection purposes.
Sign re of Permittee Date