HomeMy Public PortalAbout9715 WINDSOR LN_Plumbing__ WORKERS'COMPENSATION"DECLARATION APPLICATION FOR PLUMBING PERMIT
)ierebLo•a4firm that j have a certificate of consent to self 76A667A
inPure, or a letificate of Workers'Compensation Insurance, CE 817(REV. 10/81) J�,J
or a cerelified'• opy thereof(Sec. 3800, Lab. C.) .COUNTY OF LOS ANGELES -BUILDING AND SAFETY
Policy No.TVR67379nmpony FreM=J-
Certified-copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR.TYPE) BUILDING' ,
Certified copy is filed with the county building inspec- ADDRESS §—Winddor Dane
tion department. NUMBER FIXTURE OR ITEM @ FEELOCALITI' .` ample City
Date 10-16-86 Appligant () ,n RcmRibig WATER CLOSET
W
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. ,
COMPENSATION INSURANCE OWNER Owen Development
(This section need.not be completed If the work involved by SHOWER
the permit is for one hundred dollars($100)or less.) ,LAVATORY MAIL
.ADDRESS- 2035 S. Myrtle Ave.
I certify that in the performance of the work for which this
permit is issued, I-shall not employ any-person in any manner SINK CITY Monrovia TEL. N0.359-3211
so as to become subject to the'Workers'Compensation Laws', DISHWASHER
CONTRACTOROWen BroS.Plmlbingr InC.
Date Applicant CLOTHES WASHER 119 ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N. Baldwin Ave.
SWIMMING PO
Exemption, you should become subject to the Workers' OL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY El Monte TEL. N0.443-0078
with comply with such provisions or this permit shall be — STATE NO. 231 741 LIC
C36-20
deemed revoked. WATER HEATER
LICENSED CONTRACTORS DECLARATION 12 DISTRICT NO. up P CESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
. Class C36-7n DATE C
License Number 231 74_1Lic
_ � � n
C
FIN
C'
ContractorOwEr P1b
BrOS. M4-Dote 10-166 BY
❑ ote —8
C
I am exempt under Sec. F
B.BP.C. for this reason LCt
Plan check fee Q
Date: PLUMBING PERMIT.ISSUING FEE$ V 2
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).
CONSTRUCTION LENDING AGENCY .;2 5 8 a 4A"
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued # 0 0 0,o•0 5
(Sec. 3097, Civ. C.).
1x09450
Lender's Name o 0 o 9 4 5 0 5
Lender's Address I Q 2 9-8 6
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
a orize representatives his County to enter upon the
ova- oner�p rt f inspection purposes.
SEE REVERSE FOR-EXPLANATORY LANGUAGE
10-16-86
ignature of Permit Date