HomeMy Public PortalAbout5561 WELLAND AVE_Plumbing__ • �.� 1(y�dI ERS"COMPENSATION DECLARATION APPUCATI N FOR PLU ING PERMIT
1`�,e�ly Affirm that,l have a certificate of consent to self 76A667q
Gnsli're,.br a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Na.V8 =2379877ompany Frenwnt IdennZity '
Certified copy is hereby furnished: BUILDING 4
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 5561 Welland
Certified copy is filed with the county building inspec- '
tion department. .
NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple Cit
Date 24.1 g Sppli4ant Q[3 -T1 B O S P bg . WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB
3o DO CROSS ST.
COMPENSATION INSURANCESHOWER OWNER Jans'tar Development, Inc
('This section need not be completed If the work involved by 0
MAIL
the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS 9308 E. Valley Blvd.
I certify that. in the performance of the work for which this o
permit is issued, I•shall not employ any person in any manner SINK DD CITY Rosemead TEL. NO.280-6033
so as to become subject to the Workers'Compensation Laws.. DISHWASHER d0
67 CONTRACTOROwen Bros .Plumbing Inc.
Date Applicant 467 CLOTHES WASHERADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 100 4265 N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITYTEL.NO.
Compensation-provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM El Monte 443-007
With comply with such provisions or this permit shall be /� STATE LIC.
deemed revoked. WATER HEATER D V® LICENSE NO. 231 7.41 CLASS C36 20
LICENSED CONTRACTORS DECLARATION DISTRICT NO. R ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER -
and Professions Code,and my license is in full force.and effect. 5 PER SYSTEM FINAL VALI TION
License Number 2.31 741 Lie, Class.C36 2.0 DATE, U
Contractor Owe- Bros.,.Plbgte 712.4185 FI
g2551 A
❑ I am exempt under Sec. 10.
o 0 0 0 0 5
B.&P.C. for this reason ° 3 4 Q 5 0 0
FPIanck fee
Signature PLUMBING PERMIT ISSUING FEE$ 0. ° 3 4 0 5.,0
TOTAL FEELor 0726-85
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Low for the following reason (Section 7031.5, Business and
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 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 correi:t. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
a Ave- entioned prop . for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of Permittee Date