HomeMy Public PortalAbout9719 WINDSOR LN_Plumbing__ ",� gWORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
.•'hereby„affirm that I have a certificate of consent to self 76A667A
insure;-br a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
.br a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. I06237987impony 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 AFI69`windsor Lane
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple City
Date�Q—l6—QF Appli4ani QWgI1 Rrnc Plhrr_ WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION.FROM WORKERS' , BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER Owen Devel nt
the permit is for one hundred dollars($100)or less.) LAVATORY �, MAIL
ADDRESS 2035 S. Myrtle Ave. ,
I certify that in the performance of the work for which-this
permit is issued,1 shall not employ an person in an manner SINK CITY TEL.NO.
P P. Y rP y Monrovia 359-3211
so as to become subject to the Workers'Compensation Laws. DISHWASHER l5.
CONTRACTOR'OWIM BY'OS'. Plumbin , Inc.
Date Applicant CLOTHES WASHER
NOTICE 70 APPLICANT: If, after making this Certificate of ADDRESS4265 N_ Baldwin Ave.
Exemption,ryou should become subject to the Workers' SWIMMING POOL RECEPTOR
P P y LAWN SPRINKLER SYSTEM CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- El Mpnte 443-0078
with comply with such provisions or this permit shall be STATE 231 741 LIC' C36-20
deemed revoked. WATER HEATER �+ LICENSE NO. CLASS
' LICENSED CONTRACTORS DECLARATION DISTRICT NO, OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETSr 0� t
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
DATE f d
License Number 23 1 741 Lic. Class C36-20
FIN U
Contractor Mien BrDS. PlbgDate 10-16-86 BYzz
❑ 0-
I am exempt under Sec.
B.$P.C. for this reason ® W
Plan check fee p�
Date: PLUMBING PERMIT ISSUING FEE.$
Signature
TOTAL FEE
SINGLE FAMILY
Plan check applicant
'
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 58 0,9 A
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is'issued # o o o 0 0 5
(Sec. 3097, Civ. C.).
I '0 94, 0
Lender's Name o 0 0 9 g 5 0 6
Lender's Address 10,29-86
1 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
out rize presentative this County to enter upon the
4-197ihoture-of
- n4d p per r inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
10-16-86
Permit a Date