HomeMy Public PortalAbout9108 RANCHO REAL RD_Plumbing_1988-12-19 t� �Z,r� WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBINGPERMIT
16", affirm that I have a certificate of consent to self i 2d-0026 DPW 6/87
+nsure,i or^S certificate of Workers'Compensation Insurance, i 76A667A I 1
dr q.certified°copy thereof(Sec. 3800, Lab. C.) i COUNTY OF LOS ANGELES DEPT.OF PUBLIGWORKS L1
Policy No. 10-04896Q mp.ny CNA Ins Co
Certified copy is hereby furnished. +
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
® Certified copy is filed With the county building inspec- ADDRESS •9108 Rancho Real+ -
Tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple City
WATER CLOSET
Date 19-6-88 Appli4ant t]UTG'il Rr.n,c AT,am1„ng. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST..
COMPENSATION INSURANCE
(This section need not be completed If the work involved by + SHOWER OWNER Ron-Dearth`
MAIL
the permit is for one hundred dollars($100)or less.) ' LAVATORYa ADDRESS I certify that in the performance of the work for which this r
permit is issued,I shall.not employ any person in any manner SINK. + B�At 1 CITY I.Temple City TEL. No.286-7974
so as to become subject to the Workers'Compensation Laws. DISHWASHER
cONTRAcToR.)wein Bros. Plumbing; Inc. .
Date Applicant CLOTHES WASHER r ' ADDRESS !}265 N. Baldwin Ave.
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become sub je.4t.to the Workers' CITY TEL. NO.
Compensation provisions of the Labor Code, .you must forth- LAWN SPRINKLER SYSTEM E1 Monte 443-0078 '
with comply with such provisions or this permit shall be ' STATE 231 741 LIC• C36-20
deemed revoked. WATER HEATER r LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION . . DISTRICT NO,,•. . PR ESSED-BY,-,
I hereby affirm-that I am licensed under provisions of Chapter 9 GAS SYSTEM �, OUTLETS U
(commencing with Section 7000)of Division 3 of the Business • OUTLETS OVER
and Professions.Code,and my license Is In full.force and effect. 5 PER SYSTEM FINAL VA TION
License Number 23] 74 1 Lic. Class C36-20 DAT
FIN
Owen Bros. P1mbDate. 12-6-88 B g
s Contractor C
❑ I am exempt under Sec. W
8.06C. for this reason ► D°
Plan check fee
Date: PLUMBING PERMIT-ISSUING FEE$ Q
' Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name 1 o 1 a 5 0
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and 1 1 �5 0=5
Professions Code): City Tel. No. o o
❑ I., asowner of the property, will do the work and the I Z 9-88
structure is not intended or offered for sale (Section ® r
7044,'Business.and 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
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
i above information is correct. I agree to comply with all County polo
' ordinances and State laws regulating Plumbing; and hereby
authorize representatives of this County to enter upon the
ove- t' ned pro er for inspection purposes.
1 SEE REVERSE FOR EXPLANATORY LANGUAGE
1 •Z-CP
'gnature of Permitt Date