HomeMy Public PortalAbout6356 TEMPLE CITY BLVD_Plumbing__ • • WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I helLeFjy affvthat that I have o certificate of consent to self 200028 DPW 6/87
insure or a certificate of Workers Compensation Insurance 76A667A
or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No. 10-0489�om
04�ny CNA Ins. Co. '
Certified copy is hereby furnished BUILDING
FOR APPLICANT TO FILL IN(PRIM OR TYPE) 6356 Temple Cit Blvd
Certified copy r pled with the county budding mspec- ADDRESS P y
tion deportment NUMBER FIXTURE OR ITEM ® LOCALITY T 1
Date 5-6-92 Applitcnt Owen Bros. Plumb. 3 WATER CLOSET 14. 43 65 NEAREST
e City
CERTIFICATE OF EXEMPTION FROM WORKERS 2 BATH TUB CROSS 5T
COMPENSATION INSURANCE 2 SHOWER 29 10 OWNER Owen Construction co.
(This secflon rood not be completed R the work Imrolvod by
the permit is for ono hundred dollars MAR
($100)or loss ) LAVATORY MAILADDRESS
1 certify that in the performance of the work for which this
20,31. 2- Myrtle AveBue
permit is issued I shall not employ any person in any manner 1 Sim 14 55 CITY Monrovia TEL No 359-3211
so as to become wblecf to the Worker'Compensation Lows 1 DISHWASHER 14 55 CONTRACTOR Owen Bros. Plumbing
Dote Applicant CLOTHES WASHER 14 55 ADDRESS
NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Worker 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 231 141 UC
deemed revoked 1 WATER HEATER 14 55 LICENSE HO CL/SS
LICENSED CONTRACTORS DECLARATION DISTRICT nOPROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 1 GAS SYSTEM 5 OUTLETS 14 55 P/
(commencing with Section 7000) of Division 3 of the Bmsness OUTLETS OVER }y
and Professions Code,and my license is in full force and effect 5 PER SYSTEM FINAL VALIDATION a
Licame Number_2'A1 7111 Lic CIauC35-20.J,.6 DATE #-/7-47,, 8
Owen Bros. 5-6-92
FINAL
Contractor Dote BY
4-4 65
❑ I am exempt under Sec
B 6P C far this reason Plan check fee ItoDate Z
Signature PLUMBING PERMIT ISSUING FEE E 24175
TOTAL FEE '
SINGLE FAMILY
Pion check applicant
r
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractors License Address AL 1 T,i
Law for the following reason (Section 7031 5, Business and
Professlons Code) City Tel No 33-07 -J--9.7-
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section _
7041, Business and Professions Code) Poo jl I I FL 3 15 � 75
CONSTRUCTION LENDING AGENCY
I hereby offum that there is a consnuchon lending agency for '-HEIi' _�� yr
the performance of the work for which this permit is issued CFAW3E .fl-1
(Sec 3097, Civ C ) -
Lender s Name
Lender'sAddress
I certify that I have read this application and state that the
above information is correct I ogre@ to comply with all County
ordinances and State laws regulating Plumbing and hereby
ut onze repre3entativn of this County to enter upon the
ve mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
FOS" O°7 5-6-92
SI o ure of Perm,"" - Date