HomeMy Public PortalAbout9005 PENTLAND ST_Plumbing__ ORKERS,COMPENSATIONDEC4ARATION _ ° APPLICATION FOR
PERMIT , '
200026 DPW 4/B] �(
W,. .,Y.
rnfi1-m That I have'aWorke c Comptoof consent to self m 76A667Arn6cate of Workais Compensation Insurance,ora CE 817(REV 8/86) - - •e- `•' '
ceridied copy ihe(eof (Sec 13800 Lab C )_ .,,,: , {"+ y � •,v s '4
Policy No 100499604 Company - CNA Tnc _ Ca. "COUNTY OF�LOSLANGELES, DEPT'OF PUBLIC WORKS
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F�'s Certified copy,i's hereby furnished••. ., _ -
4, -'FOR APPLICANT TO FILL IN (PRINPOR TYPE)' , IL BUILDING t - -
� Certified copy,s filed with the county building inspection - ADDRESS ``
''deparimenl v � NUMBER ' FIXTURE OR ITEM, @ - FEE
LOCALITY a
, _ _ Temple City
i WATER CLOSET (TOILET) j - _ " s
Dole fi-78-88 Applicant Owen Broc_, Plbe � NEAREST.
's CERTIFICATE OF EXEMPTION FROM WORKERS ',j BATH TUB CROSS ST _ -
' >; •, t'COMPENSATIONlINSURANCE ,: + - , OWNER t - 't
n _.} T ' - SHOWER, . n ., ♦ + 'Chris Const a -r•- .+
(This soctlon'ro not be completed IF the work involved by t - - MAIL
the permit Is for on• hundred dollen (5100)or len ) >D LAVATORY ', ADDRESS 909 S.' Santa 'Anita Ay� #F1
c
er
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fy thatin the performance of the work for whichtfus per .. '
mitis issued I shall n61 employ any person in any manner so '�4 ' SINK . CITY ALCadld ' TEL NO 574-7354-
"
74-7354 -tc
as to become_subject to the Workers Compensation Laws �7 °
7 - .A [ �, DISHWASHER - 3� CONTRACTOR k
Dater `41 ld •Applicant '.tY' s CLOTHES WASHER `• i - Owen BIOS Plumbin Inc r� „�
ADDRESS ` '�
NOTICE TO+APPLICANT If after making this Certificate of Ex = 'SWIMMING POOL RECEPTOR 4265 N Baldwin Ave. '
'ern`ptpn yo shoo Id become,subl act to,the Workers _ - • CITY f;El Montt,' TEL No 443-0078 _
sation provisions of the Labor Code'you'must forthwith comp Js„ 'LAWN SPRINKLER SYSTEM ^
ly with such provisions or this permit shall be deemed revok STATE ' LIC "
tried , , ' o, N WATER HEATER 2 a731) i LICENSE NO - 231 -741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION, " . DISTRICT NO PROCESSED BY 4 ,
I hereby offirm that I am licensed under provoions,of Chapter GAS SYSTEM OUTLETS `
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER � }
and'Professions Code and S'y license is it'full force and of 5 PER SYSTEM ' FINALr !J �7
fact .
DATE Z11 VALIDATION .q' d
License Number 231 741 Lic Cl," 'C36-20 -
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• Tv . . p �' rs , f _ F ' U
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Contractor 'OWPTT`BrOS- PI Data 6-28-88 - ¢ `
EF I am exempt'under Sec • 4 ,� i 'W
B 8PIII
C for this reasons Y ' Plan check fee*" N
L , Data r
J PLUMBING PERMIT ISSUING FEE$ P y • 7 , 0:0 2 2 Q ,
L Signature t_ I - `
x , TOTAL FEE We • *is -'5
x "°d'��` INGLE FAMILY --�
HOME OWNER BUILDER DECLARATION - Plan check appbmnl r I '® i �it.t-�I,e
I • 3'2'2 5 0
I om hereby affirm that I am exempt frthe Contractor s License Name
Law for the following,reason (Section 7031 5, Business,ond s " , d� r-• ;[ • - 32-2505
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Professions Cade) _ t , '.6 i P , s Address `_ "' ' ' .n "
= Ob29-8y8
as owner of the property,will do the work and the City . - _ Tel No
siructuie is not intended or offered for sale(Section 7044
t,^- Business and Piofeisions Code)
' .CONSTRUCTION LENDING AGENCYp'�� , • " '� ' '"'►-' - + s
' hereby affirm that there is o construction lending agency for
the perforrnonce of the work for which this permit is issued
(Sec 3097 Cry C )
1 -
Lander s Nome
Lerider s Address
I certify that 1 have read this appl¢mion land,state that1the �• • � ' _' r _ �
above'I nformahon a correct I agree to'comply with all County o _ _ _ ► , w °v
ordinances and State laws regulating Plumbing and hereby _' ^ - ^� - ^': • - '
Quth ae epresentanves of this County„to enter upon the ', P -
e-m nedxpraper r inspector` purposes N' ,•,: , t ^! a ,t .-' ' ,
\\� SEE REVERSE FOR EXPLANATORY LANGUAGE, }'
6-28-88 T
t ignature of Permit , 't , Date