HomeMy Public PortalAbout9727 RICHMOND WAY_Plumbing__ WORKERS'COMPENSATION DECLARATION AIT"ff_ UCAT10N FOR PLUMBING PER O Il
I hereby affirm that I have a certificate of consent to self 76A667A
insu'Hf, or P certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) 'fl
�certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES EU WING AND SAFETY
Policy No7 $b2.479 - ompany Fit. - i_7
Certified copy is hereby furnished. BUILDING
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS $}t9 RicYlmOnd Way
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM R FEE LOCALITY City of Temple City
Date 10-16-86Appli4anto Wen BIOS- P1129- WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BATHTUB Aq
CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER Owen Development
(This soction need not be complotod If the work involved by MAIL
the permit Is for one hundrod dollars($100)or less.) s LAVATORY ADDRESS 2035 S.
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY Monrovia TEL. N0.359-3211
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR Owen Bros, plumbing, Inc.
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY El Monte TEL.No.443-0078
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. 231 741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION z DISTRICT NO. OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS rf,
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL fC/ VALIDATION
License Number 9-31 741 DATE 0}
Lic. ClassC'--��+-2f1
FIN C
Contractor (1< e l BMS_ P1 h.(P to 10-16-96 BYZZ 10K
❑ I am exempt under Sec. OV
B.BP.C. for this reason W
Plan check fee n,
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE 5
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). 5 8 1.4 A
CONSTRUCTION LENDING AGENCY o 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 I ° 1 0 Q 5
(Sec. 3097, Civ. C.).
OO
Lender's Name 1 0 Q 5 0 5
Lender's Address 10,29=86
1 certify that I have read this application and state that the D
above information is correct. I agree to comply with all County
ordinances and State laws re ulating Plumbing, and hereby
orize representatives o is County to enter upon the
v - t' ned pro e y r nspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignafure of Permitte Date