HomeMy Public PortalAbout6031 PRIMROSE AVE_Plumbing__ .:. a WQRKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I ��h,��Yebyoffir'm that�. limve a,certificate of consent to self 76A667A
irs'(ire, or a'certificate of'Wor�ers'Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof(Sec:'3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.0489604 . Company. Contin n al asualty
Certified copy is hereby furnished. I
BUILDING
® FOR APPLICANT To FILL IN(PRINT OR TYPE) ADDRESS 6031 Primrose
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple City.
e.
Date 2-24-87 •Appligant Owen ms- P1hq_ WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST..
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work Involved by. SHOWER V.I.P. BLiilders
the permit is for one hundred dollars $100 or less. MAIL
P ( ) ) LAVATORY ADDRESS 205 $ Blvd,
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 San Gabriel TEL. No. 309-9333
so as to becorne•subject to the Workers'Compensation Laws. / DISHWASHER
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 El 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. WATER HEATER r LICENSE NO. 231 741 cCASS C36-20
LICENSED CONTRACTORS DECLARATION WWCT NO. ,en/PROCESSP BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business; OUTLETS OVER
and Professions Code,and my license is in full force and effect.. 5 PER SYSTEM FINAL VALIDATION
License Number -231 741 f Lic.Class036-90 Ls DAT
F A C.
Contractor Owen IRms_ P1 hQDate 2-24—R7
❑ C I am exempt under Sec. �6 5 9.4 A
B.BP.C. for this reason Plan check fee ' # 0 0 0 0- b 5 n
Date: PLUMBING PERMIT ISSUING FEE$ 0 91L50'
Signature —
TOTAL FEE 0 0 0 9 4.5 0
' Plan check applicant �
SINGLE FAMILY 0227-87
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and "
Professions Code): City Tel. No.
E31, as owner of the property, will do the work and the '
structure is not intended or offered for sale (Section
7044, Business and Professions Code). pop
CONSTRUCTION LENDING AGENCY
1 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 applicat'ron'and state that the. '
above.information is correct..'I agree to comply with all County Poo
ordinances and State laws regulating Plumbing, and hereby
uthorize representatives of this County to enter upon the
-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
�-�4-8-7 •
nature of Permittee Date i