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WORKERS'COMPENSATION DECIe4RATION APPLICATION FOR PLUMBING PERMIT
I hereby affjrm,'hat 1 hove a ce*rtificate of consent to self 20-0026 DPVU 6/87
insure, or a ce►tif!cote of Workers'Comperfsotion Insurance, '76A667A
or a.cerfified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy No10-0489604comppny 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 2 1
tion department. NUMBER FIXTURE OR ITEM (q3 I FEE LOCALITY Temple City
Date 1-1-90 Appligant Owen Bros' r WATER CLOSET NEAREST
fr
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.�) �� ice,
COMPENSATION INSURANCE + OWNER
(This section need not be completed if tho work Involvod by SHOWER Owen Development
the permit is for one hundred dollars($100)or loss.) L LAVATORY �� MAIL
�:1 � ADDRESS 2035 S. Myrtle Ave.
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner i SINK ,- CITY Monrovia TEL.NO. 359-32 11
so as to become subject to the Workers'Compensation Laws. DISHWASHER ? "`
CONTRACTOR Owen Bros. Plumbing, Inc.
Date Applicant CLOTHES WASHER ti' {^
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS 4265 N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY El Mite TEL. NO.443-0078
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER ; , t� LICENSE NO. 231-741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION DISTR A
PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS /'1
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER r
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ALIDATION
License Number 231—]41 Lic. Class C36-20 DATE C
FINAL
Contractor Owen Bros. Date 9-30-91 BY C
I am exempt under Sec.
L1.
B.BP.C. for this reason Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ '
Signature
TOTAL FEE f X
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name �CCTev
I hereby off irm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and 3307 106.511Professions Code): City Tel. No.❑ I,�,E�,I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section ® TOTAL 106 o 50
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CKLCK 106.5
1 hereby affirm that there is a construction lending agency for CHAME .011the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name OCC-0-13Mi 12/13/89
Lender's Address 7491 1 AN10a 14
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 reprelentatives of this County to enter upon the
above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
r -4'i��
Sign ure of•Permitte Date