HomeMy Public PortalAbout9727 WINDSOR LN_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
!' I 16Reby affirm that I have a certificate of consent to self 76A667A
insfe, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
arta certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No�8623798xompan Fremont _
Certified copy is hereby furnished. 7 �
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS 47+9 Windsor Lane
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY Tewle Cit
Date 10-16-86 Applicant OWen Bron P1 in t3 WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' 3 BATH TUB r, CROSS ST.
COMPENSATION INSURANCEOWNER Owen Dey-elQument
(This section need not be completed if the work Involved by SHOWER
the permit is for one hundred dollars($100)or less.) LAVATORY MAIL
ADDRESS 2035 S. Myrtle Ave.
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY Monrovia TEL. NO.359-3211
so as to become subject to the Workers'Compensation Laws. -44 DISHWASHER
CONTRACTOR Bros. Plumbing, Inc.
Date Applicant CLOTHES WASHER 1ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY El Monte
TEL. N0.443-0078
with comply with such provisions or this permit shall be ' STATE LIC.
deemed revoked. WATER HEATER r— LICENSE NO. 231 741 LASS C36-20
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED B�
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �' G
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER c DD
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL / VALIDATI N
License Number 231 741 Lic. Class06-20 DATE G
FINA (C,'
Contractor Owen Bros. PlbgOate 10-16-86 BY.,
Q
Ell am exempt under Sec.
B.&P.C. for this reason Plan check fee p
Date: PLUMBING PERMIT ISSUING FEE$ ► Z
Signature t✓
TOTAL FEE 00
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). 1` '
CONSTRUCTION LENDING AGENCY J-258 1,9A
I hereby off irm that there is a construction lending agency for
the performance of the work for which this permit is issued # 0 0 0 0 a 5
(Sec. 3097, Civ. C.). ( o •) O a 5 O
Lender's Name 0 0 100.505
Lender's Address ( a29-86
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 r gulating Plumbing, and hereby
4S)6gtnature
ze r resentatives this County to enter upon the
m d`pr ert f inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
10-16-86
of Permit a Date