HomeMy Public PortalAbout9711 WINDSOR LN_Plumbing__ CORKERS'COMPENSATION DECLARATION APP1'<. CATION FOR PLUMMMIG, PE O7
k`hereby,affirm that I have a certificate of consent to self 76A667A
insure., or a certificate of Workers'Compensation Insurance, CE 817(REV.. 10/81)
::or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUBLOONG AND SAFETY �
Policy NoM_6237981-ompany Fremont
Certified copy,is hereby furnished.
' FOR APPLICANT-TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS W4_-1,.9in&or Lane.
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date 10-16-86 Appli4anf Owen Bros P1b_, WATER CLOSET 67� r NEAREST Tewle Cit
CERTIFICATE OF EXEMPTION FROM WORKERS' 12 BATH TUB j CROSS ST.
I COMPENSATION INSURANCE ' SHOWER OWNER, Owen Developnellt
(This section,need not be completed If the work involved by
MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS 2035 S. Myrtle Ave,.
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY Monrovia TEL.N0.359-3211
so as to become subject to the Workers'Compensation Laws. DISHWASHER .r
/— CONTRACTOR�� Bros. Plumbing, Inc.
Date Applicant CLOTHES HER
(%
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS 4265 N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING-POOL RECEPTOR
Compensation provisions of the Labor Code,,you must forth- LAWN SPRINKLER SYSTEM CITY TEL.Monte ��'NO'443-0078
with comply with such provisions or this permit.sholl be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. 231 741 C36-20
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P OCESSED BY
I hereby affirm-that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS D f�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER (J
and Professions Code,'and my license is in full force and effect. 5 PER SYSTEMFINAL VALBDATBON
License Number-731 741 Lic. Class 1736-7f1 DATE ' C
Contractor OWen Br s- P11=.Date 10-16-86
❑ I am exempt under Sec. C
BAP.C. for this reasonW
Plan check fee - p,
Date. PLUMBING PERMIT ISSUING FEE$ Z
Signature -
TOTAL FEE-
Plan checkapplicant - • •_ _
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). Jr 8 1.3 A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for I # 0 0 0 0 0 5
the performance of the work for which this permit is issued I ° 1 0 Q 5 0
(Sec. 3097, Civ. C.).
OQ50�
Lender's Name 1
1029-86
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
orize r pressentatives of s County to enter upon the
ov -m
7ned pro y r ' spection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
fi-
10-16-86
(gnature of Permitfe Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0901060019
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: FEES PAID I BUILDING ADDRESS: T
ITR: 43189 LT: 7 1 9711 WINDSOR LN ]
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803964
(
(ASSESSOR INFORMATION NUMBER: I NEAREST CROSS STREET:
18589-019-041 101 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY, Cl
I 147 WATER HEATER(S) 1.00 WTH 16.20 T I
1TENANT: I TOTAL FEES 43.95 (ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 1
101/06/09 SR 07/05/09 T
I
TOWNER: TEL. NO: I (FINAL DATE FI CODE: I
IWONG ADDISON Y;DENISE C (626) 309-9958-
19711 WINDSOR IN
I�
TTEMP 917803964 I IDESCRIPTION OF WORK
] I [REMOVE/REPLACE GAS WATER HEATER [
(APPLICANT: TEL. N0: [
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IHOME DEPOT (800) 454-8955-
I12601 132ND. AVE NE ISPECIAL CONDITIONS:
IKIRKLAND, WA 98034 I T ]
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ICONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE I
[HOME DEPOT (800) 454-8995- I
T12601 132ND AVE NE LIC. NO ]UNDER SLAB WORK
IKIRKLAND WA 98034 602331 1
1 I (WATER SERVICE I I
T I IPLASTIC Y/N METAL YIN I I
(ARCHITECT OR ENGINEER: TEL. NO:
1 I IROUCH PLUMBING I I I
LIC. NO:
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[GAS VENT I I
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1 (PLUMBING FIXTURES
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ILAWN SPRINKLERS I I I
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(UTILITY COMPANY NOTIFIED( I I
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]REPORT ID: DPR263 ROUTE TO: BS0508 I I I
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