HomeMy Public PortalAbout9714 RICHMOND WAY_Plumbing__ J : .'WORKERS'COMPENSATION DECLARATION A'VPTUCATION FOR PLUMBING PERMOT
'herehy affirm that I have a certificate of consent to self 76A667A
insure, or a cer4ificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NoIV86M7ompanyF )nf- '
Certified copy is hereby furnished. { /
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUIL51-N9704 Richmond Way
® 'Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY :TM le Cit
Date 10-16-86 Applicant ObOn RMEL P113g- 3 WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
a BATHTUB- 1 CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER Owen Development
(This section need not be completed if the work involved by
the permit is for one hundred dollars($100)or less.) MAIL
Ll LAVATORY a ADDRESS 2035 S. Myrtle Ave.
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner I SINK CITY Monrovia TEL.No.359-3211
so as to become subject to the Workers'Compensation Laws. / DISHWASHERCONTRACTOR Owen Bros. Plumbing, Inc.
Date applicant CLOTHES,WASHER ADDRESS 4265 N. Baldwin Ave.
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR '
Exemption, you should become subject to the Workers' CITYTEL.NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM El Monte 443-0078
with comply with such provisions or this permit shall be STATE LIC.
deemed.revoked. WATER HEATER LICENSE NO. 231 741 c C36-20
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR SSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ! p
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER 4
and Professions Code,and my license is in full force and effect. 5,PER SYSTEM FINAL VALIDATION
DATE / a
License,Number 231 741 Lic. Class 1716-2177
FIN Q
Contractor Owen Bros. P1bCfDafe 10-16-86 BY
❑
I am exempt under Sec. C�
B.BP.C. for this reason
Plan check fee Lp,
Date: v1
PLUMBING PERMIT ISSUING FEE$ 0 Z
Signature
TOTAL FEE
SINGLE FAMILY
Plan check applicant ,
_
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address ,4
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. �1 a
❑
I, as owner of the property, will do the work and the •ti
structure is not intended or offered for'sale (Section D °t'''>r'•: ti
7044, Business and Professions Code). 5 8 Q 7,A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for # 000,005
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). 10 - 04,50
Lender's Name 94505
Lender's Address. 1 0,29-4-86
1 certify that I have read this application and state that the o
above information is correct. I agree'fo comply with all County
ordinances and State laws re lating Plumbing, and hereby
KyizVere
resentati s o s County to enter upon the
meqLpr e y r spection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
10-16-86
ignature of Permitt Date