HomeMy Public PortalAbout5325 WELLAND AVE_Plumbing__ `WORKERS'COMPENSATION DECLARATION APPLICATION/k° ION FOR PLUMBING PERMIT
I 76A666 DPW 4/87 /°Or �.rM i�5
I hereby, affirm that I have a certificate of consent to self in- 76A667A
sure,or q certificate..of Workers`Compensation Insurance,or a CE 817(REV. 8/86) e
certified copy thereof(Sec. 3800, Lab. C.)
Policy No. 994965 Company Rep• Indemnity COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Welland Avenue
Certified copy is filed with the county;bu�ildd' g inspection ADDRESS 5325
department. NUMBER FIXTURE OR ITEM (d FEE
Q LOCALITY TEMPLE CITY, CA
Date 6/24L�Applica WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB, of �O CROSS ST.
COMPENSATION INSURANCE SHOWER9 /O OWNER Mur-Sol, Inc.
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY � ADDRESS132 La Porte
I certify that in the performance of the woik for which this perOF-
mit is issued, I shall not employ any person in any manner so SINK CITY Arcadia TEL. No8/447-0558
as to become subject to the Workers'Compensation Laws. DISHWASHER
1-41 CONTRACTOR Frank Marrone & Sons, Inc.
67
Date Applicant CLOTHES WASHER
ADDRESS 9860 Lower Azusa Rd.
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen-
sation provisions of the Labor Code,you must forthwith comp-, LAWN SPRINKLER SYSTEM. CITY E1 Monte TEL. No8/444-2548
ly with such provisions or this permit shall be deemed revok- STATE LIC. -
ed. WATER HEATER ✓l— LICENSE NO. 397884 CLASS C/36
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ?J�
7(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER O
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM 8`3 FINAL VALIDATION
lett. DATE �y
License Number 397884 Lic. Class C/36 C/16 � Z-Z6 00
F. Marrone & Sons 12/31/92 FINAL
Contractor Date BY 0
❑ I am exempt under Sec. O
B.&P.C. for this reasonri•;y
Plan check fee _.__•!a_:g
Date: I PLUMBING PERMIT ISSUING FEE$ 7 1_ ?
Signature -• - .....
TOTAL FEE ''',''�' '-3 i: f
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant t:in:
;..:
I hereby affirm that I am exempt from the Contractor's License Name
Low for the following reason (Section 7031.5, Business and
Professions Code): Address
❑ I, as owner of the property, will do the-work and the City Tel. No.
structure is not intended or offered for sale(Section 7044, ;.r;
Business and Professions Code).
CONSTRUCTION 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. 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
b' ' ed property for inspection urpo es.
,,// w_� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date