HomeMy Public PortalAbout9722 WINDSOR LN_Plumbing__ 4 _ iWORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hdreby•pffirm that I have a certificate of consent to self 76A667A
insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
ofra certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELESU DING AND SAFETY
Policy NoIV8623798Zompany Fremont # Y
❑. Certified copy is hereby furnished. r
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDIN TAT1ndSOr Lane
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM (g FEE
10-16-86 WATER CLOSET _ LOCALITY T le Cit
Date Appli4ant 0fn1e1'1 BrOS. Plba. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' a BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER Owen Development
(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
— CONTRACTOR Owen Bros. Plumbing, Inc.
Date Applicant CLOTHES WASHER ' ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- El Monte 443-0078
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM
STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
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
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINA
DATL VALIDATI
License Number 231 741 Lic. Clossr-46-20 J V
Contractor OInTe B R- P1 hersp110-116-86 -
F L• 0
ate 1 n-1 ti-86
❑ I am exempt under Sec. U1
B.BP,C. for this reason yDate: Plan check fee ► �
PLUMBING PERMIT ISSUING FEE$ O
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). 5 8 0i 0 A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for # 0 0 0 0 0 5
the performance of the work for which this permit is issued
'(Sec. 3097, Civ. C.). i•'o 0'94.5 0
Lender's Name 000911,50-um
Lender's Address 10.2 9—8 6
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
au orize representatives this County to enter upon the
ov - on&d prdmart r inspection purposes.
ky
10-16-$6 SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittv Date