HomeMy Public PortalAbout5401 WELLAND AVE_Plumbing__ G"IORKERS'COMPENSATION DECLARATION APPLICATION
k Ppe IC/4 TION FOR PLUMBING
PERMIT
nereby,'Offirm that I have a certificate of consent to self in- �6AD667A PW•4/87 /`1 �"L /'� ®�!7 r L>, i�197 �Vi n
••,sura;or a.certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) 'ul
certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT.'.OF•PUBLIC.WORKS':.
Policy No.1 00489604 Company CNA I_ns _
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
® Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM @ FEE ADDRESS 5401 Welland,.
department.
LOCALITY Temple City
Date 5-18-88 A licant Owen BroS Pl g• WATER CLOSET(TOILET)" �
PP � NEAREST,
CERTIFICATE OF EXEMPTION FROM WORKERS' � 3
BATH TUB CROSS ST,
COMPENSATION INSURANCE SHOWER OWNER Owen Development
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS 2035 S. _Myrtle Ave.
I certify that in the performance of the work for which this per- SINK �. CITY TEL. NO.
mit is issued, I shall not employ any person in any manner so 359-3211
as to become subject to the Workers'Compensation Laws. / DISHWASHER .
CONTRACTOR Owen Bros. Plumbing, Inc.
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR4269 N. Baldwin Ave.
emption,you should become subject to the Workers'Compen- CITY TEL.NO,
cation provisions of the Labor Code,'you must forthwith comp- LAWN SPRINKLER SYSTEM E1 Monte 443-0079
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. 231 741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED BY
I hereby affirm that I am'licensed under provisions of Chapter GAS SYSTEM OUTLETS i [ �fC
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER (/
d Professions Code, and my license is in full force and ef- 5 PER SYSTEM= FINAL q V (DATION d
fe
DATE
License Number 991 741 Lic. Class 1036-90 �V O
• V
FIN
Contractor Owen Rrnc_P1 ho_Date. 5-18-88 BY O
❑ I am exempt under Sec. W
B.BP.C. for this reason ® U)
Plan check feecp% z
Date: PLUMBING PERMIT ISSUING FEE$
Signature TOTAL FEE � 02 9.6 a 5 A
SINGLE FAMILY # 0 0 0 0 0 5
HOME OWNER-BUILDER DECLARATION Plan check applicant . .
1 hereby affirm that I am exempt from the Contractor's License Name 1 - 20250
Law for the following reason (Section 7031.5, Business and
Professions Code): Address o - 2 0 2 5 0"
I, as owner of the property, will do the work and the City Tel. No. o 52 5-ac 8 g
structure is not intended or offered for sale(Section 7044,
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
*aor.1zer eresentatives f this County to enter upon the
ned p er or inspection purposes.
5-18-88SEE REVERSE FOR EXPLANATORY LANGUAGE
ure of Permiftew Date