HomeMy Public PortalAbout9708 RICHMOND WAY_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR P"LUtfV MNIG, PERMIT
I hereblt nffirm that I have a certificate of consent to self 76A667A
S ifisu4r,�or a certificate of Workers'Compensation Insurance, CE 817(REV 10/81)
ora certified+copy thereof (Sec. 3800, Lob C I COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NoTVA6717c) Jompany F_r4Mpa t �/� �� 08
Certified copy is hereby furnished. �—
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �z"'R1cYlmond Way
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM (rd FEE ADDRESS LOCALITY Temple City
Date 1 Q-1 6—R6 Applicant QATW RrgS P_Ijbigr WATER CLOSET — Aq NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB _, CROSS-ST.
COMPENSATION INSURANCE SHOWER OWNER DevelO t
(This section neod not be completed If the work Involved by MAIL
the pormit is for ono hundrod dollars(3100)or less.) J M LAVATORY ADDRESS 2035 S. Myrtle Ave.
1 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 Monrovia TEL. NO.359-3211
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR Owen BIOS. plUMbing, Inc.
Date Applicant J CLOTHES WASHER ADDRESS 4265 N. Baldwin Ave.
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY El Monte TEL.NO.443-0078
with comply with such provisions or this permit shall be STATE
231 741 LIC
CENSE NO. .
deemed revoked. WATER HEATER �+ CLASS C36-20
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS r 6,—D
(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
DATE !c a
License Number 231 741 Lic. Class 6-20 C
FI L (;
Contractor Omen Bros, PlbQDate 10-16-86
f3:
❑ C
I am exempt under Sec,
B.BP.C. for this reasonLL
Plan check fee LIS,, a
Date: pr Cf.
PLUMBING PERMIT ISSUING FEE$ LAI
Signature m
TOTAL FEE D
Plan check applicant
SINGLE FAMILY
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): I 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 and Professions Code).
CONSTRUCTION LENDING AGENCY 5 d 1. ( 1
I hereby nffirm that there is a construction lending agency for I
the performance of the work for which this permit is issued , 0 0 0 0 0
(Sec. 3097, Civ. C.). 1 1 0
Lender's Name o .. 1
Lender's Address 1 0 29—F6
I certify that I have read 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
a orize representatives this County to enter upon the
o oned p ert inspection purposes
•� SEE REVERSE FOR EXPLANATORY LANGUAGE
10-16-86
ignature of Permit ee Date
L