HomeMy Public PortalAbout9718 WINDSOR LN_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificateof consent to self 76A667A.
insyag,or a Sertificate of Workers'Compensation Insurance, CE 817-(REV. 10/81)
a s if copy thereof(Sec,3800; Lab. C.)
COUNTY OF LOS ANGELESUILDI.NG AND SAFETY.
ti.• olicy None 7 zompony Frt-mnnh r;
Certified copy is hereby furnished.
BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) "
Certified copy is filed with the county building inspec- ADDRESS 1974.8. .IriC�SOr 'Carie,.:,.
tion department. NUMBER- FIXTURE OR ITEM @. FEE LOCALITY
city
10=16-$6 Owen Bros. Plw—
WATER CLOSET _ TWV1Q
NEAREST
Date Applicant CROSS ST. +'•
CERTIFICATE OF EXEMPTION FROM WORKERS' O�
BATHTUB ^
COMPENSATION INSURANCE SHOWER OWNER Owen Developlment'`
(This section need not be completed if the work involved by
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS 2035 S. MyMAIL rtle Ave.
I certify that in the performance of the work for which this
permit is issued, I shall not employ an person In an manner SINK CITY TEL:'NO. - .
p p r vp Y Monrovia 35.9-32'1T
so as to become subject to the Workers'Compensation Laws. DISHWASHER.
Al CONTRACTOR
QMfi BMS, Plumbing., Tnc-:-
Date Applicant / CLOTHES WAS ADDRESS 4265 N. Baldwin Ave.
NOTICE TO APPLICANT: if, after making this Certificate of SWIMMING POOL RECEPTOR -
Exemption, you should become. subject to the Workers'
Compensation provisions of-the Labor Code, you must forth- LAWN SPRINKiER SYSTEM CITY El. Monte TEL.NO.443-00'78
Monte—
with comply with such provisions or this;'permit'shall be STATE LIC.
deemed:revoked. LICENSE NQ... 231_._741: CLASS.. -C36-20 .
, WATER HEATER ,
LICENSED CONTRACTORS DECLARATION DISTRICT'NO.. PAOCESSED BY
I hereby Affirm-that I am,licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of:"Division 3 of.,'the. Business OUTLETS OVER
and Professions Code,and my license is.in full force and effect. S PER SYSTEM. FINA •VALIDATIO.
License Number 231 .741 Lie. Class C3.6-20 DATE.
.
Contractor Owen B s, P1bcTDate . IG--i"- 6
0 1 am exempt under Sec. ,
_ H
BAP.C. for this reason a
Plan check:fee
Date: PLUAIIBIIVG PERMIT ISSUING FEE-$ " z
Signature.. P
-' '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.El 4 i �, •x'
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
I:hereby affirm that there is a construction lending agency for '_ A 5 8 Q 5 A
the performance of the Work for which'this permit 'is issued
(Sec. 3097,Ci.v. C.). # cg00o5
1 0 0 94+50
Lenders Name
Lender's Address ° ° ° 9�.5 a v
I certify that I have read this application and state that the I Q 2
above information is'correct. I agree to comply with all County 9 i$.6
cjrdi. nces and.State laws regulating Plumbing, and hereby• ►
au rite represents've o this County to enter upon the
v -m i e;pr a f r Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
igna :ture.of Permi e 0 Date,