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HomeMy Public PortalAbout5118 ROSEVALE DR_Plumbing__ WORKERS CI have a certificate DECLARATION rAPPLICATION FOR PLUMBING PERMIT {1 • u I hereby afkum that I have a certificate of consent to self 7yyo7q 'insyte ora certificate of Workers Compensation Insurance CE 817(REV 10/81) dr a cert,f'ed copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No 40489604 Company (`n+,n + l Certified copy is hereby furnished © FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 5118 N. Rosevale Certified copy Is filed with the county building inspec ADDRESS hon department NUMBER FIXTURE OR ITEM ® FEE LOCALITY Tenple City Date 2-5-87 Applicant Owen EIMR- Mg. WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB Aa ^ CROSS ST COMPENSATION INSURANCE OWNER Owed COILStrilCtlOn (This section need not be completed If the work Involved by SHOWER the perrrrlt Is for one hundred dollars (1100)or less ) wvnioRv �— MAIL 20j5 $ 1 Ave. I certify that m the all not employ the work for which this manner SINK OTY Monrovia TEL No 359-3211 Permit is Issued I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws DISHWASHER CONTRACTOR Owen BIOS. Plumbing, Inc. Dole 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 No443-0078 with comply with such provisions or this permit shall be STATE llC deemed revoked WATER HEATER �. LICENSE No 231 741 CSS C36-20 LA LICENSED CONTRACTORS DECLARATIONDly BY I hereby offvm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS `` (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code and my license is in full face and effect 5 PER SYSTEM FINAL VA ATION License Number. 231 741 L,c Cluu C36-20 DATE '� O FINAJIU Connactor«n BIOS. P1bCI.Dote2-5-87 BY//,M fY ❑ O am exempt under Sec 0 U B 8P C for this reason Plan check fee aa.. Dare Signature PLUMBING PERMIT ISSUING FEE 1 a 6 4 8 5 A z }( } F 5 g TOTAL FEE SINGLE FAMILY Plan check applicant e e - 9&505 HOME OWNER BUILDER DECLARATION Nome I hereby affirm that I am exempt from the Contractor s License 0 21 0-87 Low for the following reason (Section 7031 5 Business and Address Professions Code) Guy Tel No ❑ 1, as owner of the property, will do the work and the , structure is not intended or offered for sole (Section 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY I hereby affirm that there iso construction lending agencyfor 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 4909'nature onze reprelentotrves up -on this County to enter uon the ve honed pr a for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 2-5-87 of Permi a Dote WORKERS COMPENSATION cafeDECLARATION corse APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76AeO7A � �J insure W cercifi iteiof Workers Compensation Insurance CE 817(REV 10/81) �f�o p cPry d copy thereof ( ec 3800 C ) �S71'N BUILDING AND SAF tPO tyWWNo�r olBpony Certified copy is hereby furnished FOR APPLICANT TO FILL IN(PRIM OR TYPE) BUILDING �Cerhhed copy j,filed with the county build] nspec- ADDRESS tion depart en NUMBER FIXTURE OR ITEM ® FEE ^X��%, LOCALITY �- Dale ��LApphca WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST COMPENSATION INSURANCE OWNER (This section need not be completed H the work Involved by SHOWER the permH Is for one hundred dollars (11100)or less ) MAIL LAVATORY I certify that in the performance of the work for which this ADDRESS permit is issued, I shall not employ any person in any manner SINK O CITY TEL NO so as to become subject to the Workers Compensation Laws DISHWASHER J� V• CONTRALTO Date Applicant CLOTHES WASHER NOTICE TO APPLICANT If after making this Certificate of 46 ADDRESS Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CRY TEL NO with comply with such provisions or this permit shall be STATE LIC deemed revoked WATER HEATER dLICENSE NO 7 CLASS LICENSED CONTRACTORS DECLARATION DISTRW NO ssED eY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS rE (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER C V V and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL /-3 DATE Z VALID ION License Number� Li"Z�LJ— Lm Class mac,../, FIN Contract Dote( ��' r B Q 8 ❑ I am exempt under Sec O h- B 8P C for this reason W Plan check fee D_ Dore PLUMBING PERMIT ISSUING FEE$ Signature ? TOTAL FEE ;2641. 1 A Plan check applicant SINGLE FAMILY # e e • • • 5 HOME OWNER BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor s License e e 9 4 5 0 Law for the following reason (Section 7031 5 Business and Address Professions Code) City Tel No s s s 9 Q,5 0 5 ❑ I as owner of the property, will do the work and the , O 1,27-87,2 7 y 8 7 structure is not intended or offered for sale (Section 70" Business and Professions Code) CONSTRUCTION LENDING AGENCY I hereby offirm 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 IcertifA that I have read this application and state that the ► above formoti is correct I agree to comply with all County ordina es an ate laws regulate ng Plumbing and hereby autho za re re n hues of Ihis County to enter upon the oboe -men ion d operty for mspecrion purposes f^ SEE REVERSE FOR EXPLANATORY LANGUAGE Si otura Permt�ee Dote 1 r f {� affirm that I have certificate DECLARATION DPW 9189 APPLICATION FOR PLUMBING PERMIT lJ 76Aae1A I hereby aliKm that I hove a certificate of consent to self Insure or a certificate of Worker s Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) _ CC COUNTY OF LOS ANGE Policy No Company LES CEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV ❑ Certified copy is hereby fumrehed 1 ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE)dopartCerulfied copy re filed with the coumy bu0tling Inspection tlepartmem NUMBER FI%TURE OR REM ® FEE LOCALITY Date Appilcam WATER CLOSET NEAREST CERTIFICATE OF D(EMPTION FROM WORKERSCROSS STH COMPENSATION INSURANCE KITH TUB ASSESSOR (Title section rrosd not M completed N the work Involved by the SHOWER MAP BOOK PAGE PARCEL permit Is for one hundred dollars($100)or leu) OWNER I certify that in the performance of the work for which this permit LAVATORY IS Issued I Shell not employ any person in any manner so as toSINK MAILADD �O become Subject to the Workers Compensation Lowe /�/�Q/� DSWASFER CIT TEL NO��/C Data ApPlvant NOTICE TO APPLICANT If alter CLOTHES WASHER eking thio Certificate of CONTRACTOR provisions you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR .yy `��//� pronelona of the Labor Cade you moat forthwith comply with each AGGRESS / (/ J provolone or this permit shell be deemed revoked i LAWN SPRINKLER SYSTEM t LICENSED CONTRACTORS DECLARATION WATER HEATER CITY �I%��JNT TEL Np/ I hereby affirm that I em licensed under provisions of Chapter S Profa(commwa ds Section 7000)of in full f 3 0l the Business and GAS SYSTEM LETS LICENTE SE NO (��/<0/ GLASS Profeaerans Cade and my license is In full farce and effect l.7 OUTLETS OVER DIST; SSED BY Q 6 PER SYSTEM O _ Q License Number Lic Claes V contractor Date DATE V TION W ❑ am .empF.underSao INAL INSPECTION B SP C for Ove reason Date Plan check fee Signature PLUMBING PERMIT ISSUING FEE$ , 0 L — ❑ TOTAL FEE SINGLE FAMILY Plan check apt HOME amOWNER exempt ptfrom BUILDER DECLARATION Nemo 'L I hereby affirm that on exempt from the Business a a License Lew for the following reason (Section 7031 6 8usineee and Professions Address ."._ �..+...,�•� Code) 2 r ❑ I u d owner the property will do the work entl the structure Is not Intended w offered for sale (Section 7W d, Business City Tel No �n3 po 1 and Professions Code) Poo. tq- VqS CONSTRUCRON 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 3087 Ch C) Leder a Name Lander a Address I certify that I have read this application and state that the above 100.Information Is ca"m I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above mentioned Property for Inspection SEE REVERSE FOR EXPUMATORY LANGUAGE