HomeMy Public PortalAbout9715 RICHMOND WAY_Plumbing__ AWQRKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
r ,,�/.oy affirm that I have a certificate of consent to self 76g667A
iniTsl4, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES SUI DING AND SAFETY
Policy NcIN786 7 87-ompany FrPtnnnf- —
Certified copy is hereby furnished. /±7Pol
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 97$5®
Certified copy is filed with the county building inspec- ADDRESS 9 q$5 Richmond Way
tion department. NUMBER FIXTURE OR ITEM � FEE
LOCALITY Temple Cit
Date 10-16-86 ApplicaninUPn Rmg_ Plb WATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB r CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed If the work involved by MAIL
the pormit is for ono hundred dollars($100)or loss.) LAVATORY ADDRESS 2035 S. Myrtle Ave.
I certify that in the performance of the work for which this SINK CITY MOnrOvia TEL. NO.359-3211
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. DISHWASHER r
CONTRACTOR Owen Bros. Plumbing, Inc.
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY El Monte TEL. No.443-0078
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE 231 741 LIC. C36-20
deemed revoked. WATER HEATER LICENSE NO. C SS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR ESSED BY
1 hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ('7 VALIDATIO
231 741 DATE
License Number Lic. Class C36-20
FI L (0j
ContractorOWen Bros. P1bQ.Date 10-16-86
❑ I am exempt under Sec. O
B.$P.C. for this reason ® 15
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Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ Z
Signature
TOTAL FEE '
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address r
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ 1, 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 5 8 Q 6 A
CONSTRUCTION LENDING AGENCY ! 0 0 0 0 0 5
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued 9 5 0
(Sec. 3097, Civ. C.).
o ,.1C2
Lender's Name 10 ` 9_8 6
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
pop-
ordinances and State laws regulating Plumbing, and hereby
4g'natuZre
ize r resentatives o this County to enter upon the
ed�pro y inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
AA.10-16-86
o Permitte t. Date