HomeMy Public PortalAbout9708 WINDSOR LN_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
I
nsure,.or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
or certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.131$ $$ompany FreTTLOnt
Certified copy is hereby furnished. BUILDING
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS °9499- Windsor Lane
Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM @ FEE
tion department. LOCALITY
WATER CLOSET Temple City
Date 10-16-13� Appliganf �rPn RmG_ P1� NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' a BATH TUB f CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER Owen DevelO nt
(This section need not be completed if the work Involved by MAIL
the permit is for one hundred dollars($100)or loss.) LAVATORY ADDRESS 2039 q- Myri-Ilt- Autn_
I certify that in the performance of the work for which this SINK CITY TEL. NO.
permit is issued,I shall not employ any person in any manner Monrovia 359-3211
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR Owen Bros. Plumbing,
Date applicant CLOTHES WASHER ADDRESS 4265 N. Baldwin Ave.
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM El Monte 443-0078
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. 231 741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR CESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER • ! O
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL / !VALIDATION >
231 741 C36-20 DATE n
License Number Lic.Class C
Contractor Olden BrOS. P1}JCfDate 10-16-86
E] I am exempt under Sec. H
B.BP.C. for this reason n
Plan check fee
Date. PLUMBING PERMIT ISSUING FEE$ Q
Signature
TOTAL FEE 5-20
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): I City Tel. No.
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section 2 5 8 Q 1 A
7044, Business and Professions Code). k
CONSTRUCTION LENDING AGENCY # 0 0 0 0 0 5
1 hereby affirm that there is a construction lending agency for 10 0 9 1L 5 0
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). 0 0 0 9 4 5 0
U
Lender's Name 1 0.29-86
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 10>
ordinances and State la regulating Plumbing, and hereby
a horize epre'sentativ f this County to enter upon the
ov - 'oned o rt for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
JA 10-16-86
nature of Per VIC
Date