HomeMy Public PortalAbout5321 WELLAND AVE_Plumbing__ "1. ORKERS'COMPENSATION DECLARATION G"z P L ECA 1 OGN FOR PaU WNG PERAA9 T
. jI"hereby•affirm that I have a certificate of consent to self 20-0026 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 �J
Policy No. 994965 Company_ Ra=n Tnaemni ty
Certified copy is hereby furnished. )
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING5321 We l Yand Avenue
❑ Certified copy is filed with the county building insAJ11pec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE
WATER CLOSET
.3 LOCALITY TEMPLE CITY, CA
Date 6124/92 Appliga
NEAREST I'
CERTIFICATE OF EXEMPTION FROM WORKERS' i. BATH TUBl� CROSS ST.
9
COMPENSATION INSURANCE OWNER jMur—Sol, Inc.
p�
(This section.need SHOWER /Q eed no4 be completed if the work Involved by Mull 132 La Porte
the permit Is for one hundred dollars($100)or'less.) LAVATORY -10 ADDRESS I.
I certify that in the performance of the work for which'this SINK CITY . Arcadia TEL.x,647-0558
permit is issued, I shall not employ any person in any manner !, f
so as to become subject to the Workers'Compensation Laws. I, DISHWASHER
. CONTRACfcfrank Marrone & Sons, Inc.
Date Applicant CLOTHES WASHER
'ADDRESS 9860 Lower Azusa Rd.
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY E l :Monte' L, NO. 444-2548
P P Y I LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE84788/+ LIC. C/36
deemed revoked. 1. WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION ; DISTRICT NO. PROCESSED BY
I hereby offirm-that I am licensed under provisions of Chapter 9 �; GAS SYSTEM OUTLETS ,{,�p .
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER ?, �/ (/
and Professions Code,and my license is in full force and effect. I', 5 PER SYSTEM 93 FINAL � VALIDATION
397884 C/36 C/16 I; D 03PS DATE �F2`-�+,
License Number Lic. Class
Contractor Bate Marrone & Son 12/31/92 .12/31/92 FINAL
BY
❑ I.am exempt under Sec.
I LIU
B.BP.C.for this reason
Plan check fee .t.<`°° CC
Date: PLUMBING PERMIT ISSUING FEE$
Signature-
' TOTAL FEE - 305 Co—''
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name ;_Fki
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): City TeL No. T,
❑ - ,
I as owner of them ert , will do the work and the + Tai 7�
structure is not intended or offered for sale (Section FM
•°a
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY I'
I hereby affirm that there is a construction lending agency for I;
the performance of the work for which this permit is issued is
(Sec. 3097, Civ. C.). I
I 1
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
authorize repre$entatives of this County to enter upon the
ob -mentioned'property for inspection purposes.
or SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ature of ermittee at