HomeMy Public PortalAbout9723 RICHMOND WAY_Plumbing__ %.1 r ® nn PLUM �p
b%KERS'COMPENSATION DECLARATION APPLICATION FOR MNG PERM
I heoeWor'firm that I have a certificate of consent to self 76A667A
"-!Wre, 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 BUILDING AND SAFETY
Policy NoW86237987ompany F=m �3
Certified copy is hereby furnished. BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDINGADDRESS Richmond Wa
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM (off FEE
LOCALITY 1e Clt
Date 10-16-86 AppligantQW1nn Rmc P1bg WATER CLOSET r �-
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' 3 BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER Owen Develo t
(This section need not be completed If tho work Involved by MAIL
the permit Is for ono hundred dollars($100)or less.) LAVATORY ADDRESS 2035 S. Myrtle Ave.
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK �- CITY MOI1rOVla TEL.N0.359-3211
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR Owen Bros, Pllmibing, Inc.
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY El Monte
L'NO'443-0078
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. 231 741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION DISTRICT P CESSED BYE
I hereby offirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER '57
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
License Number 211 247 Lic. Classr —20 DATE v
FIN (�
Contractor Owen DIMS, P1bgDote 10-16-196 BY
❑ I am exempt under Sec. IL
B.&P.C. for this reason LL
Plan check fee n
Date: PLUMBING PERMIT ISSUING FEE$ Q
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
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). 9 5 8 1.5 A
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for # 0 0 0 0 0 5
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). I o 100.50
Lender's Name
- 10Q5025
Lender's Address
I (129-86
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 re ulating Plumbing, and hereby
a orize repressentati es is County to enter upon the
bove- t ned pro t o inspection purposes.
I 10-16-86 SEE REVERSE FOR EXPLANATORY LANGUAGE
gnoture of Permit e ( Date