HomeMy Public PortalAbout5947-5947 1/2 PRIMROSE AVE_Plumbing__ O ER_Sr CMPEN9ATION' ECLARATI.ON APPLICATION FOR PLUMBING PERMIT
er�eby, irm that{?have'b certificate of consent to self in -20-0026 A 4/87 n
sure;;or;p certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86) 'dull
dbrtified copy thereof(Sec. 3800, Lab. C.)
Company TnG n. COUNTY OF LOS ANGELES DEPT. OF.PUBLIC
WORKS-
olicy No.100489604 Compa
ki. 7
Certified copy is hereby furnished.
�s filed with the count building p FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING;
Certified co y l • .
py,• y bgins inspection ADDRESS 59� Primrose
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY ,
Date 3-25-88Applicant OWen Br0 . Mg, WATER CLOSET(TOILET) NEAREST l'
BATH TUB 1 CROSS ST.
' C�RTIFICAIE OF EXEMPTION FROM WORKERS' BA �. . ,;
COMPENSATION INSURANCE SHOWER OWNER Richard Dea"rth.,
(This section need not be completed if the work involved by, MAIL :i ...I
%,
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS 5945 Primrose `•
Ikertify that in the performance of the work for which this per- SINK
mit is issued, I.shall not employ any person in any manner so CITY Tem le Cit TEL. N0.286-7974
as to become subject to the Workers'Compensation Laws. DISHWASHER .�
CONTRACTOR Owen Bro s.. r Plumb in Inc.
Date Applicant CLOTHES WASHER ,, I
ADDRESS 4265 N. Baldwin 'Ave.
NOTICE TO APPLICANT: If, after making this Certificate'of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY E1 Monte TEL. NO.443-0078
6ation provisions of the Labor Code,you must forthwith comp: LAWN SPRINKLER SYSTEM
ly with such provisio4 or this permit shall be deemed revok- STATE LIC.
ed. ;, G, WATER HEATER LICENSE NO. 231 741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION. DISTRICT NO. OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 07, GAS SYSTEM OUTLETS r
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER' ±
fe d•Professions.Code, and my license is in full force and ef' 5 PER SYSTEM FINAL. ./ r VALIDATION
DATE ILO
License Number-231' 741 Lic. Class 1736-90 0
FIN
Contractor'OwenBros_ P1bg Date 3•-95-88 BY O
'I am exempt under Sec. W
B:$P.C. for this reason ►
Plan check fee '
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY-
HOME OWNER-BUILDER"DECLARATION Plan check appticant-
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and
Professions Code): Address
1, as-owner of the property, will do the work and the City. Tel. No.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). 9 2 6 8 A
CONSTRUCTION LENDING-AGENCY 0 0 0 0•0 5
I hereby affirm'that there is a construction lending agency for
the.performance of the work for which this permit is issued 5 0
(Sec. 3097, Civ. C.).
Lender's Name
oUP99`
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 qpoll
dinances•and State laws regulating Plumbing, and hereby
ut a representatives of this County to enter upon the
b ve- ntioned prope or inspection purposes.
�8 SEE REVERSE FOR EXPLANATORY LANGUAGE
ature of Permittee Date