HomeMy Public PortalAbout6162 ROSEMEAD BLVD_Plumbing__ 4.iKERS'C09cNSh 'ON DECLARATION APPLICATION FOR PLUMBING PERMIT
i as,id;)Faffirm that I have a certificate of consent to self 76A667A
nsoro;or a certificate of Workors'Componsation Insurance, CE 817(REV 10/81)
or a fortified copy thereof(Sec. 3800, Lab C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.TVR4237(4 mpany Freman.t I.ndemmity
Certified copy is hereby furnished.
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
(�
Certified copy is filed with the county building inspec- ADDRESS Rosemead Blvd
tion department. NUMBER FIXTURE OR ITEM �1 FEE LOCALITY
PMPTe City
Date 10--31-84 Appligant QwLnn Rrnc P1 ha_ WATER CLOSET (per � NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE I SHOWER OWNER Rosemead Construction
(This section need not be completed if the work involved by MAIL
the permit Is for one hundred dollars($100)or less.) 3 LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY San Gabriel TEL.NO.573-4110
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR oWen
Bros. 1 bin Inc.
Date. Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N Baldwin Ave.
,
Exem tionyou should become subject to the Workers' SWIMMING POOL RECEPTOR
p y I CITY TEL.NO
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM '443-0078
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER B_ LICENSE NO. 231 741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION 1v DISTRICT NO. =Y4
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS `(J/1
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER l!
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDAT N
License Number P31 741 Lic. Class /2 —2n DATE3;�� V
FINA 9-1
ContractorOWen RrOS- Plhg-Date 10-31.-84 BY 10
❑ I am exempt under Sec. P a.
1 7a.0n t!D
B.BP.C. for this reason
Date:
Plan check fee 00. 0 0 0 0 o j
PLUMBING PERMIT ISSUING FEE$
Signature FO I o o R 8, 0TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name o o c f f
I hereby affirm that I am exempt from the Contractor's License Address
Low for the following reason (Section 7031.5, Business and ( V :' /i
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
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 information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
Aa orize representatives of this County to enter upon the
m tioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
re of Permittee Date