HomeMy Public PortalAbout6360 TEMPLE CITY BLVD_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 200026 DPW 6/87
insure or a certificate of Workers'Compensation Insurance, 7BA667A
or a certified copy thereof (Sec 3800, lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No 10-0489WApan y CNA Ins. Co.
Certified copy Is hereby furnished
n Certified copy is filed with the county building Inspec- FOR AFRICAN 70 FILL IN(PRINT OR TYPE) ADID�REu Temple Cit Blvd
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y{+ non department NUMBER FIXTURE OR ITEM ® FEE LOCALITY
Date 5-6-92 Owen Bros. Plumb. 3 WATER CLOSET 14. 43 65 T
AppllGant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' I BATH TUB rCROSS ST
COMPENSATION INSURANCE OWNER Owen,Construction co.
(This section need not be completed If the work Inwlved by 1 SHOWER 14 55
NN permit Is For one hundred dellen (1100)or leuMAIL) LAVATORY —ADDRESS I certify that In the performance of the work for which this
permit is Issued, 1 shall not employ any person in any manner 1SINK CITY Monrovia TEL NO 359-3211
so as to become subject to the Workers Compensation Laws 1 DISHWASHER 14 55 CONTRACTOR Owen Bros. Plumbing
Date— Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM cin El Monte TEL 443-0078
with comply with such provisions or this permit shalt be STATE 231 741 LIC C36-20-16
doomed revoked 1 WATER HEATER 14 LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO Sp PROCESSED 8� ,
I hereby affvm that I am licensed under provisions of Chapter 9 1 GAS SYSTEM 5 OUTLETS 14 55
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER �
and Professions Cada,and my license is in full force and effect 5 PER SYSTEM FINAL VALIDATION O:
License Number x„11 741 Lic Claud DATE 8
Owen Bros. 5-6-92 FINAL a
Contractor Data BY O
❑ ~
I am exempt under Sec p
W
B 8P C for this reason Plan check fee acn
Date PLUMBING PERMIT ISSUING FEE$ `j ?
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOMEOWNER-BUILDER DECLARATION Name A((T.t
I hereby affirm that I am exempt from the Contractors License
Law for the following reason (Section 7031 5 Business and Address 337
Professions Code) City Tel No
El1 !TDO
I, as owner of the property will do the work and the
structure is not intended or offered for sale (Section , I OTI L 3 15 - 75
7044 Business and Professors Code)
CONSTRUCTION LENDING AGENCY "14EC Y. ^1U.75
I hmeby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec 3097 Gv, C ) '
Lender's Name nn[rit-rl;[li `{ 715'
Lender it Address G 1140 1 All r %_IJ
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
authorize representatives of this County to enter upon the
bove mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Q 5-6-92
Si Qature of Permittee Date