HomeMy Public PortalAbout9726 RICHMOND WAY_Plumbing__ S WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A I I
insure,,or certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) u
or a certified copy thereof (Sec. 3800,Lab. C.) COUNTY OF LOS ANGELES J31L11WING AND SAFETY
Poicy NoTVR623-7-g xompany Evnmm,� �
Certified copy is hereby furnished. _4z -
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
aCertified copy is filed with the county building inspec- ADDRESS 9@44--Richmond Way
tion department. NUMBER FIXTURE OR ITEM Q FEE
LOCALITY Temple Cit
Date 10-16-86 Appli;antQ0 n BIDS- Pll=- aj WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB -- CROSS ST.
COMPENSATION INSURANCE OWNER Owen Development
(This section need not be completed If the work Involved by MAIL
SHOWER
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS 2035 S. M rtle Ave.
I certify that in the performance of the work for which this ZVI
permit is issued, I shall not employ any person in any manner f SINK CITY MonroviaTEL. NO. —
so as to become subject to the Workers'Compensation Laws. / DISHWASHER CONTRACTOR OWM BrOS. Plumbing, Inc.
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY El Monte TEL. N0.443-0078
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. 231 741 CLASS C3620
LICENSED CONTRACTORS DECLARATION / GAS SYSTEM OUTLETS DISTRICT NO. ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 ` G t
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER G
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINA —9 VALIDATIO
DATE — a
License Number 231 741 Ltc. ClossIC36-20 C
FI (;
ContractorOweri Bros. P1bCr ate 10-16-86 B r
❑ I am exempt under Sec. C
B.BP.C. for this reason LL
Plan check fee a
Date:
Signature PLUMBING PERMIT ISSUING FEE$
e
TOTAL FEE D
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 F 8 1,7 A
I hereby affirm that there is a construction lending agency for 0 0 0 0 0
the performance of the work for which this permit is issued # O
(Sec. 3097, Civ. C.). 0 9 G Q 5 0
Lender's Name 0
Lender's Address ( 0.2 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 _
ou ri&ofPermitteeC
'sentativ s of County to enter upon the
ove- d prop f pection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
10-16-86
i nature Z Date