HomeMy Public PortalAbout9723 WINDSOR LN_Plumbing__ it S VyORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
.I hereby affirm that I have a certificate of consent to self 76A667A
insure, pv a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No-TV8623798ompany ZrEMQ t - /,�a — A#D -2
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS '�j indsor Lane
tion department. NUMBER FIXTURE OR ITEM ® FEE
LOCALITY rl'eIII 1e Clt
Date 10-16-86 AppliganfOWPn Rena Plbg-- WATER CLOSET /41 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' 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($100)or less.) z J 12 LAVATORY ADDRESS 2035 S. Myrtle .Ave.
I certify that in the performance of the work for which this /
permit is issued,1 shall not employ any person in any manner / SINK CITY Monrovia TEL.NO'359-3211
so as to become subject to the Workers'Compensation Laws. / DISHWASHER
CONTRACTOR Owen Bros.PlUmbing, Inc.
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY El Monte TEL- NO. 443-0078
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS D O
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER j
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL /� VALIDATION
License Number 731 741 Lic. Class('(-20 DATE ✓ O.
FIN (Cd
Contractor0wan Bros. P1bg Date 10-16-86 BY
❑ I am exempt under Sec. H
B.BP.C. for this reason LL
Plan check fee p
Date: PLUMBING PERMIT ISSUING FEE$ Q
Signature LSD
TOTAL FEE rg .50
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.
❑ 1, 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). f#L
CONSTRUCTION LENDING AGENCY ° 100.50
1 hereby affirm that there is a construction lending agency for ` s
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). I Q29—P6
Lender's Name
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
aut rize representatives of his County to enter upon the
00€m ed prop y nspection purposes.
OWSEE REVERSE FOR EXPLANATORY LANGUAGE
U1 10-16-86
VigZnaatureof Permitte Date