HomeMy Public PortalAbout5323 WELLAND AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION LOCA L1 �ON FOR PLUMNNG PERMIT
I '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 certif{gd copy thereof (Sec. 3800, Lab. C..) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy No.994965 Company Rep Ind mniy
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS. 5323 Welland Avenue
NUMBER FIXTURE OR ITEM ® FEE
tion department. LOCALITY, TEMPLE CITY, CA
Date 6/24/92 Appli4a WATER CLOSET NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' Id
COMPENSATION INSURANCE SHOWEROWNER Mur—Sod Inc.
(This section need not be completed If the work Involved by
the permit is for one hundred dollars($100)or less.) LAVATORY Sk DDRESS132 La Porte
I certify that in the performance of the work for which this
permit Is Issued,I shall not employ any person in any manner SINK CITY Arcadia TEL.NOB/447-0558
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR Frank Marrone & Sons Inc.
Date Applicant CLOTHES WASHER ADDRES99860 Lower Azusa Rd.
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL. N
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM E 1 Monte NCB/444-2548
with comply with such.provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. 397884 CLASS' C 36
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm-that I am licensed under provisions of Chapter 9 / GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER3
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
License Number S,�
397884 Lic. Class3b r/1 DATE �� `�(p �0,
FINAL
Contractor F JAarrnno R. Cnfe 12.4 3 1 /09 BY 0
❑
I am exempt under Sec. 0W
BAP.C. for this reason n-
Plan check fee Z
Date. PLUMBING PERMIT ISSUING FEE$ '
Signature 7s Pi� 1
TOTAL FEE
Plan-check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name ;l:l j ,305
I hereby affirm that I am exempt from the Contractor's License Address f''�-;""� i
Law for the following reason (Section 7031.5, Business and =3 1
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 AGENCYPM
r;.•, . ..
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
authorize representatives of this County to enter upon the
abo a-men oned property for inspection p pose .
�jn ' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date