HomeMy Public PortalAbout6035 PRIMROSE AVE_Plumbing__ ti' + WORKERS'COMP.EN$ATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby.bffir;r 'ffiat'•I have a`'certificate of consent to self 76A667A
' insure, or a certificate of tiNorkers'Compensation Insurance, CE 817(REV. 10/81) IJ
or a certified copy thereof (Sec. 380CF, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
e Policy No. 0489604 Company CMH nenta l C'acUalty
❑ Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 6035.Primrose
®
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM FEE
LOCALITY Z+ 1
e City
Date 2-24-87 Applicant niiagnn Rmg_ Pl bc; WATER CLOSET k 161
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST. }
COMPENSATION INSURANCE OWNER V..I.P. Builder
(This'section need not be completed if the work Involved by SHOWER
MAIL
the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS 205 .San Gabriel Blvd.
I. certify that in the performance of the work for which this SINK San Gabriel TEL.NO.309-9333
permit.is issued,I shall.not employ any person in any.manner o CITY
so as to become subject to the Workers'Compensation Laws. DISHWASHER
` CONTRACTOR OWP_Il BrOS. Plumbing, Inc.
Date Applicant r CLOTHES WASHER ADDRESS(�
NOTICE.TO APPLICANT: if, after making this Certificate of 4265 N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY El M011te TEL. No•443-0078
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked•. WATER HEATER. s LICENSE NO: 231 741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
.I hereby affirm that I amlicensed under-provisions of Chapter 9 GAS SYSTEM OUTLETS .r
(commencing with Section.700D)of Division 3 of the Business OUTLETS OVER "
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
f
License Number 231 741 Lit. ClassC36-20 _ DATE .8
Contractor
FI
Contractor Owen Brox_ P1 bQDate. 2-74—R7 B
❑ I am exempt under Sec. R 6 5 9,6 A
B.O.C. for this reason 'Plan
a 0 0 0 0 5 OW..
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$, i 0 0 94.5 0 z
Signature
TOTAL FEE o 0 o 9 4.5 0 5
SINGLE FAMILY
Plan check applicant 0227-87
-
HOME OWNER:BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address
Professions Code): - City Tel. No.
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business arid-Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(See. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I haveread 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 and
of this County to enter upon the
b entioned pro erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
2-24-87
nature of Permittee Date