HomeMy Public PortalAbout5407 WELLAND AVE_Plumbing__ .�' •. -` aNORKERS%COMPENSATION DECLARATION
',-of�i m that I have a certificate of consent to self in- 76A667 DPW I APPLICATION FOR PLUMBING PERMIT I
C CE 817 A
%4su�e,or a.certlficate of Workers'Compensation Insurance,ora CE 817(REV. 8/86) '
certified copy thereof (Sec. 3800, Lob. C.)
Policy No. 100489604 Company CNA n,q, CO, COUNTY OF LOS ANGELES DEPT. OF PUBLIC-WORKS
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 (d FEE ADDRESS. . . .540 Welland,
department. LOCALITY
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em C'
Date 5-18—.88 ---:Applicant Owen Bros WATER CLOSET(TOILET) le. t.Plbg, NEAREST 5.
CERTIFICATE OF EXEMPTION FROM WORKERS'
C
BATH TUB ROSS ST. '
COMPENSATION INSURANCE // OWNER
O� SHOWER Owen Develo went
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY .ADDRESS
I certify that in the performance of the work for which this per- 2035 S. Myrtle
/ SINK -�
mit is issued, I shall not employ any person in any manner so 6 CITY Monrovia TEL. NO-359-3211
as to become subject to the Workers'Compensation Laws. DISHWASHER
• CONTRACTOR Owen Bros. Plumbing, Inc.
Date Applicant / CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR4265 N_ Baldwin Ayp.
emptio,n,you should become subject to the Workers'Compen- CITY E1 Monte TEL. N0443_0078
sation provisions of'the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
lywith such provisions or this permit shall be deemed revok- STATE LIC
d .
WATER HEATER LICENSE NO. 231 741 CLASS C36-20 i
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRQeESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS s ^
9(commencing with Section 7000)of Division 3 of the'Business OUTLETS OVER
fed Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VA D ION }
DATE a
License Number 231 741 Lic. Class C36-20 ✓ O
FINA V
ey cc
Contractor Owen Bros- P1 hon�,te 5-1 R—RA BY 0
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V
I am exempt under Sec. �9 6� W
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o
B.&P.C. for.fhis reason Plan check fee ( ® # 0 0 0 0 W
Date:-' PLUMBING PERMIT ISSUING FEE$ ( 2 \�
Signature _ YYY
TOTAL FEE
SINGLE FAMILY ° 2
HOME'.OWNER-BUILDER DECLARATION Plari check applicant �a � 0 525-88
5_8 8
I hereby affirm that I am exempt from the Contractor's License Name
Law 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,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction•lending agency for ;g 9 6 9.O A
the performance of the work for which this permit is issued 5
(Sec. 3097, Civ. C.). #.!0 0 o o a
Lender's Name 1 0 2 0 2 5 0
Lender's Address - - 202503-
1
0202503-
1 certify that I have read this application and state that the O 5 2 5-+8 8
above information is correct. I agree to comply with all County
or inances and State law regulating Plumbing, and hereby
>a t rize Fted
esenta've f this County to enter upon the
v -m pr e y r inspection purposes.
5-18-88 SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ature of Permi a Date