HomeMy Public PortalAbout11201 WINDSOR LN_Plumbing__ ., WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
a.
I.hereby gifi,4 that I have a certificate of consent to self ,i 76A667A
insure, or a certificate of Workers'Compensation Insurance, 1,1 CE 817(REV. 10/81)
or a certified copy thereof(Sec. 3800, Lab. C.) ! COUNTY OF LOS ANGELES BUILDING AND SAFETY
olcy No. mpany Freiii nt — 7�
J Certified copy is hereby furnished.
I FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
i ® Certified copy is filed with the county building inspec- ADDREsi-97T Windsor T.ane
tion department. NUMBER FIXTURE OR ITEM (� FEE LOCALITY Temple City
I Date 10-1 6-86 Appligant CXAMn BM--- Pl hg— 3 WATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' a BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER Owen Development
(This section need not be completed If the work Involved by
the permit is for one hundred dollars($100)or less.) LAVATORY n MAIL
o� ADDRESS 2035 S. Myrtle Ave.
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK. �' CITY Monrovia TEL. NO.359-3211
so as to become subject to the Workers'Compensation Laws. DISHWASHER
c°"TRE`croROwen Bros. Plumbing, Inc.
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N•. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM clrY El Monte TEL. NO443-0078
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. 231 741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ✓ VALIDATION
231 741 C36-20 DATE a
License Number Lic. Class
FI � C(;
ContractorCklPn Bms- Plhq-Date 10-16—Rh
a
❑ I am exempt under Sec. C
B.BP.C. for this reason ® Lt
Plan check fee p,
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL-FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law 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). --pe 5 7 9 9 A
CONSTRUCTION LENDING AGENCY # 0 0 0 0 0 5
1 hereby affirm that there is a construction lending agency for ° ° 9 4,5 0
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). o o a 9 Q,5 0 5
Lender's Name I (129-86
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
4/ i
orize repre'sentati es this County to enter upon the
e- ned pro t inspection purposes.
.. SEE REVERSE FOR EXPLANATORY LANGUAGE
0-16-86
ature of Permitt a Date