HomeMy Public PortalAbout9707 WINDSOR LN_Plumbing__ t � Fes.•; WORKERS'COMPENSATION DECLARATION
4 .APPLICATION FOR PLUMBING PERMIT
tf s I he�b-y affirm that I have a certificate of consent to self 76A667A ' I
insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) u
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANIGELESUIL INIG AND SAFETY
Policy No. TV86 - 7 &1,pany p gnnni- _ Q
Certified copy is hereby furnished. BUILDING '
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS �— indSor L
Certified copy is filed with the county building inspec- _
and
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple•city
Date 10-16-86 Appligant Offen 13rnS_P11xg_ WATER CLOSET f NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work Involved by SHOWER Owen DevelO nt
the permit is for one hundred dollars($100)or less.) LAVATORY -� MAIL
ADDRESS 2035 S. Mpztle Aye.
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK -� CITY Monrovia TEL-NO.359-3211
so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR
Owen Bros. Plumbing, Inc.
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N. Baldwin Ave.
Exemption, you 'should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM El Monte 443-0078
with comply with such provisions or this permit shall be LSTATE ICENSE NO. 231 741 LIC.
SS C36-20
deemed revoked. WATER HEATER 1
LICENSED CONTRACTORS DECLARATIONDISTRICT NO. OCESSED BY
I hereby affirm-that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commenting with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL7 VALIDATION
License Number- 231 747 Lic. Class C36-9n DATE �f a
-- p L
Contractor Owen Srn-c;- P11=-Date In-16—�_
❑ I am exempt under Sec. C
B.&P.C. for this reason LCi
Plan cHeck'fee a
Date: -PLUMBING PERMIT ISSUING FEE$ �� Z
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. :•:�:: `` r :yti,,` ��,, a .•` y
❑ I, as owner of the property, will do the work and the k
structure is not intended or offered for sale (Section " ' , --;258Q-3A-
7044, Business and Professions Code). ' i
CONSTRUCTION LENDING AGENCY "# ° a .° ° 05
1 hereby affirm that there is a construction lending agency for J ° 1 0 Q 5 0
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). ° ° 1-0 Q 5 0.60
,'Lender's Name VQ 2 9'—8 6
Lender's Address
1 certify that I have read this application and state that the D
above information is correct. I agree to comply with all County -
ordinances and State laws regulating Plumbing, and hereby
auth ize r re'sentati s this County to enter upon the
a . -me d .ro e y o inspection purposes.
SEE REVERSE FOR EICPLAWATORY-LANGLIAGE
10-16-86
Si nature of Permitte Dote