HomeMy Public PortalAbout10648 OLIVE ST_Plumbing__ r WORKERS'COMPENSATION'DECLARATIQN APPLICATION FOR PLUMBING PERMIT
t herejiy affirm that I have a certi#lebw of cdfisent to{'self 20-0026 DPW 6/67
insure, or a certificate of Workers'Compensati3n Insurance, 7GA667A
4s or a certified copy thereof(Sec. 3800, WIS. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
P licy No. 10-04896Q�bmpany CNA Ins. Co. ti
Lf Certified copy is hereby furnished. i BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 10644 Olive S t.
Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM @ FEE
tion department.
� LOCALITY Temple Cit
Date-1—1—90 Appligant Owen Bros, 1 umbin WATER CLOSET Uu
NEAREST �
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB - CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER Owen Development
(This section need not be completed if the work involved by
the permit is for one hundred dollars($100)or less.) LAVATORY �� MAIL ADDRESS 1 2035 S. Myrtle Ave.
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK CITY I Monrovia TEL.NO. 359-32 11
so as to become subject to the Workers'Compensation Laws. I DISHWASHER 5 CONTRACTOR
Owen Bros. Plumbing, Inc.
Date Applicant CLOTHES WASHER ADDRESS 4265 N. Baldwin Ave.
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY I E1 Monte TEL.No.443-0078
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. t WATER HEATER �� LICENSE NO. 231-741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION _ , QISTRI NO PROCESSED BY
GAS SYSTEM OUTLETS l h
I hereby affirm that I am licensed under provisions of Chapter 9 ` ( � c J
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is to full force and effect. 5 PER SYSTEM FINAL ` ALIDATION
231-741 DATE I
p�
C36-20
License Number Ltc. Class V
FINAL
Contractor-Owen Bros. PlmbDate 9-30-91 BY ' O
❑ I am exempt under Sec. LU
B.BP.C. for this reason I t1
Plan check fee en
Z
Date: PLUMBING PERMIT ISSUING FEE$
Signature !�
TOTAL FEE I u i 150
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name ACC a4
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and 3307 10Qo1
Professions Code): City Tel. No.❑ ITEMS
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section TOTAL 100 0 50
7044,-Business and Professions Code).
CONSTRUCTION LENDING AGENCY CHECK 100.50
I hereby affirm that there is a construction lending agency for �y
the performance of the work for which this permit is issued CHANGE .00
(Sec. 3097, Civ. C.).
Lender's Name 0000...0001 12/13/89
Lender's Address 74889 1 AM1011 13
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 representatives of this County to enter upon the
gbove-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Per itte' 'ter Date