HomeMy Public PortalAbout9719 RICHMOND WAY_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT {�
:ti hereby offi`'m that I have a certificate of consent to self 76A667A u
Mr,re or 6'2tertificafe of Workers'Compensation Insurance, CE 817(REV. 10/81)
or a ;ertified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES B ILDING AND SAFETY
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❑olicy No.106 3798$ompany Pg�mnni- — D _ 7
Certified copy is hereby furnished.
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS COnd Way
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date 1Q-16-8tiApplicant Okmn Ry-nsAlbg WATER CLOSET 2' le Clt
_
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' a BATH TUB CROSS ST.
COMPENSATION INSURANCE / OWNER
(This section need not be completed If the work Involved by SHOWER Owen Development
MAIL
the permit is for one hundred dollars($100)or loss.) -I—QV 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 �' CITY MppVj a TEL. N0359-3211
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR OWen $rOS. Plumbing, Inc.
Date Applicant / CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N. Baldwin Ave.
you subject,
Exem tionshould become suect to the Workers' SWIMMING POOL RECEPTOR
Exemption, Y I CITY El Monte TEL. No. 443-0078
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. 231 741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR ESSED`Y
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATIO
License Number 231 741 DATE a
Lic. Class V16-2n
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L
ContractoXIwen Bros. Plba.Date 10-16-86 Y
❑ I am exempt under Sec. H
B.&P.C. for this reason G
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ L
Signature —
TOTAL FEE �Q
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
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 55 S 1.0 A
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued #j? 0 0 0 0 0 5
(Sec. 3097, Civ. C.). I o 1 0 a 5 0
Lender's Name
0 oI uCt ,r,' 0
Lender's Address I a 2 9—8 6
1 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 or",fpre'sentotives County to enter upon the
ove spection purposesSEE REVERSE FOR EXPLANATORY LANGUAGE
10-16-86
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