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Home My Public Portal About5423 ROSEMEAD BLVD_Plumbing__ Wr KERS' COMPENSATION DECLARATION c L e4PPLICATION FOR PLUMBING PERMIT • �13d1t? I hereby b ism thet I hove m certificate of consent to self 76A667A - fl insure, o a certifi:cate'of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof (Sacr'3800, Lab. C.) COUNTY OF LOS ANGELES._. _..- .BUILDING AND SAFETY.. Policy No. Company ❑ Certified copy is hereby furnished. - FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ❑ Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY 9 Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE _ OWNER t (This section need not be completed if the work involved by SHOWER _ MAIL; the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS 1 certify that in the performance of th work for which this e 77 permit is issued, I shall not employ any r on in any manner SINK - CITY,j TEL. 7-1 so as to become subject to the rl`ers pensation Laws. DISHWASHER r 4 CONTRACTOR, Date -A licant - CLOTHES WASHER NOTICE TO APPLICANT:pf, after making this Cert icate of ADDRESS .•a Exemption, you -should become subject to the Workers' SWIMMING POOL RECEPTOR -' 1-3f - Compensation provisions of the Labor Code, you must forth- CITY r/'� TEL. N �� LAWN SPRINKLER SYSTEM i with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS s LICENSED CONTRACTORS DECLARATION DISIA<TN9, PROCPM BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS. l (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effe t. 5 PER SYSTEMFINAL 1 _. . _._ VALIDAAIN Q i j 00 DATE License Number ` Lic. Class �r j� O Contractor �� 1) —+�/u Date /' BY AL ❑ ' 1 am exempt under Sec. O F- 8.8P.C. for this reason ;2 7.7 5.1 A W Plan check fee p„ Date: #•0 010 0 0 5 Cl) Signature PLUMBING PERMIT ISSUING FEE$ 3 ®' TOTAL FEESO 1•0 -2250 Plan check-6 iic5nt --- _... . SINGLE FAMILY pp a - 0 2 2 5 Oil HOME OWNER-BUILDER DECLARATION Name awai I hereby affirm that I am exempt from the Contractor's License ' 0 a 2 6,", $7 Low for the following reason (Section 7031.5, Business and Address - 5-1199 d Professions Code): City Tel. No.-016 7 ❑ 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 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). _ _. _....-_ Lender's Name Lender's Address _ . _. .......... .... I certify that I have read this application and state that the above i .formation is correct. I agree to comply with all County ordinan a d State laws regulating Plumbing, and hereby authoriz esentatives cf this County to enter upon the ove-m io ed proper for inspection pur ores. G ,� SEE REVERSE FOR EXPLANATORY LANGUAGE• ignature Permittee Date _.._._. .-... .- -_ -..... ._.. _. _..._. y.w .WORKERS''COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT ""I-hereby,affirm that I have a certbficctte of consent to self 76A667A insure, or a certificate of Work�ers' Compensation Insurance, CE 817(REV. 8/86) or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy NoIo- 8-96 Company CNA Ins-. Co. Certified copy is hereby furnished. ' FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS MOD&K 5423 N. Rosemead Blvd. tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple City 9-2-87 Owen Bros. Plb Inc. WATER CLOSET Date Applicant g'� NEAREST ' CERTIFICATE OF EXEMPTION FROM WORKERS" BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER Ohanis SHOWER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORYADDRESS 565 S. Lake I certify that in the performance of the work.for which this permit is issued, I shall not employ any person in any manner SINK CITY Pasadena TEL. NO.796-6777 so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOROWeri BrOS. Plbg., Inc. Date Applicant CLOTHES WASHER ADDRESS 4265 N. Baldwin Ave, NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY El Monte TEL. No. 443-'0078 Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM .with comply with such provisions or this.permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT N� lo CESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS '' r (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER J19. and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL LIDATION 10 231 741 C36 20 DATE Q License Number Lic. Class 0 FINAL Contractor Owen Rmg_ Plbg Ckne 9-9-97 BY ININ ❑ I am exempt under Sec. B.BP.C. for thispeason Plan check fee Da PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name 2 7 8 ra 5A I hereby affirm that I am exempt from the Contractor's License Address Law for.the following reason (Section 7031.5, Business and # o a o o o5- Professions 5- Professions Code): City Tel. No.❑ 0 0 1 65 1, as owner of the property, will do the work and the structure is not intended or offered for sale (Section ® •o o o 1, 65 05 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for 9 0 8,�--8 7 the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name 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 ordinances and State laws regulating Plumbing, and hereby authorizer presentatives of this County to enter upon the e'-m n i �d pro ert inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permi a Date . } 1 WORKERS' COMPENSATION DECLARATION20-0026 APPLICATION FOR PLUMBING PERMIT I he'�eby, affirm that have a certificate of consent to self in- 76A667A PW 4/87 sure,or a cef'tificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS. ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING`/•(� J U3 8O eo teq, Certified copy is filed with the county building inspection ADDRESS 6� department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY N Date Applicant WATER CLOSET(TOILET) NEAREST 3 r1 � // CERTIFICATE OF EXEMPTION FROM WORKERS'' BATH TUB CROSS ST. / �/��w COMPENSATION INSURANCE OWNER 0,y1gW11r /"j� SHOWER - (This section need not be completed if the work involved by MAIL < /�� the permit is^for one hundred dollars ($100)or less.) LAVATORY ADDRESS 51-12-3 '0 0Se1)11&4 � v d, N e perform nce of the work for which this per- shall no play -person in any manner so SINKCITYS n �� TEL NO�O? ,Q17ubject o orkers'Compensation Laws. DISHWASHERCONTRACTORApplicant CLOTHES WASHERLICANT: If, after making this Certificate of Ex- ADDRESS SWIMMING POOL RECEPTOR M emption,you should become subject to'the Workers'Compen- CITY TEL. NO. cation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT '/ P CESSED BY I hereby affirm that I am licensed under provisions-of Chapter GAS SYSTEM OUTLETS V OY 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER andt Professions Code, and my license is in full force an--J ef- 5.PER SYSTEM FINAL LIDATION DATE �� O License Number Lic. Class U FINA f$ O Contractor Date BY _ J U 0 1 am exempt under Sec. B.&P.C. for this reason Plan check fee ® z 9 0�5 A Date: PLUMBING PERMIT ISSUING FEE$ 1 1 S # o o 0 010 5 Signature TOTAL FEE19 - 2250 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant .0 0 0 2 2 5 Q xo I hereby affirm that I am exempt from the Contractor's License Name 224-88 Law for the following reason (Section 7031.5, Business and Q Wstructure scions Code): _ Address I, as owner of the property, wiII'do the work.and the City Tel. No. is not intended or offered for sale(Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm-that there is a construction lending agency for the performance of-the work for which this permit is issued (Sec. 3097, Civ_C.). Lender's Name Lender's Address I certify that I have read this application and state thot the above infor n is correct.•I agree to comply with all County ordinances a d Stlaws re uloting Plumbing, and hereby authorize re ?_6ti of this County to enter upon the abov ion d per spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE f ig Permittee -Date ,-