HomeMy Public PortalAbout9718 RICHMOND WAY_Plumbing__ 'r WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I IN166y affirm that I have o certificate of consent to self 76A667A
in0re, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
or o.cerfifilld copy thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUI DING AND SAFETY
Policy No. mpany RZ= (a 71
Certified copy is hereby furnished.
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) _ BUILDING $`Richmond Way
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM � FEE LOCALITY
Date10-16-86 Applicant OWen G Pl Mhi ng 3 WATER CLOSET NEAREST Temple City
CERTIFICATE OF EXEMPTION FROM WORKERS' 3 BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
SHOWER Owen DevelO nt
(This section need not bo complotod if the work Involved by MAIL
the permit is for one hundrod dollars($100)or loss.) LAVATORY ADDRESS 2035 S. Myrtle Ave.
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK t CITY Monrovia TEL NO.359-3211
so as to become subject to the Workers'Compensation Laws. / DISHWASHER 1
CONTRACTOR Owen Bros. Plumbing, Inc.
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N. Baldwin Ave
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITYTEL.NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM El Monte 443-0078
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. 231 741 CLA,% C36-20
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRO ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS a_6
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER ,4
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINA VALIDATI }
License Number231 741 DATE "O,
O.
Lic.Class��H-7n
FIN d
Contractor OWP_n Bros. P1bQdate 10-16-86 BY 4a f
❑ C
I am exempt under Sec.
B.BP.C. for this reason ® a
Plan check fee
Date: Cr
PLUMBING PERMIT ISSUING FEE$ 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
Law for the following reason (Section 7031.5, Business and
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 ® 5 81.6 A
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY # 0 0 0 0 0 5
I.hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued ( ° 1 0 Q 5 0
(Sec. 3097, Civ. C.). 0 I , 0 r 0 U
Lender's Name 1 029-86
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 PO
ordinances and State laws regulating Plumbing, and hereby
4, nv
ze re re'sentativesdois County to enter upon the
me d prop tnspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
10-16-86
re of Permute Date