HomeMy Public PortalAbout5405 WELLAND AVE_Plumbing__ r `'WORKERS'COMPENSATION DECLARATION APPLICATION
FOR PLUMBING
PERMIT
.'•+I,hereby;'affirm that I have a certificate of consent to self in- 76'0626 DPW a/87 /`1r r 9 a@ 0�11'4ltl S`li PERMIT
76A667A
' r sure,'b,►a certificate of Workers'Compensation Insurance,ora CE 817(REV. 8/86)
certified copy thereof(Sec. 3800, Lab. C.)
4 COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS-:
Policy No. 10048960Company CNA' Tng Cn_
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 'ADDRESS 5'405 Welland
department. @ FEE
LOCALITY
Date 5-1 R-RR A licanf Qwt-n Brnc P1 by- WATER CLOSET(TOILET)
PP �' NEAREST ";. •, � ,
BATH TUB CROSS ST,'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCESHOWER ✓ OWNER aK 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 $. M Ttle Ave.-"
1 certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY Mon TEL. NO.rOV La 359-3211
as to become subject to the Workers'Compensation Laws. DISHWASHER r .
11 CONTRACTOR Owen Bros. Plumbing, Inc.
Date Applicant CLOTHES WASHER ✓
NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS 4265 N win Ave.
emption,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR
sation provisions of the Labor Code, ou•must forthwith comp- CITY E1 Monte TEL NO. 443-0078
P Y P- LAWN SPRINKLER SYSTEM
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. PRQCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER (!
fed Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINALV DATION d
DATE Zi
License Number 731' 741 Lic. Class C3(-90 O
U
FBI N C
Contractor Owen &OR p bagate 5-18—$8
I am exempt under.Sec. W
a
B.&P.C. for this reasonW
Plan check fee ® z 9 6 a 8'A
Date: PLUMBING PERMIT• ISSUING FEE$
Signature # 0 0 0 0 0 5
TOTAL FEE
SINGLE FAMILY Plhk licanf /►j� /J ( - 20250
an ceca
HOME OWNER-BUILDER DECLARATION PP v
I hereby affirm that I am exempt from the Contractor's License Name ° o 2.0 2 5 0 U
Law for the following reason (Section 7031.5, Business and a25-88
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,
Business and Professions Code). _ z
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
Vbe
r r�sentafi s this County to enter upon the
ed prop f rinspection purposes.
5-18-88 SEE REVERSE FOR EXPLANATORY LANGUAGE
e of Permitt Date