HomeMy Public PortalAbout9932-9934 WOODRUFF AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION ,, ®® F:,. PLUMB
ING PERMIT :
I hereby affirm that I have g certificate of consent to self 'cE en (z-eo) P"
insure,or a certificate of Workers'Compensation Insurance,or .!f+
a certified copy thereof(Sec.3800'L3b.C.) s COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.WC67917 Comy
Certified copy is hereby furnished. FBER
R APPLICANT TO FILL IN (PRINT OR TYPE.) BUILDING 9932 - 9934 Woodruff
ADDRESS
Certified copy is filed with the unty uildin in pection FIXTURE OR ITEM ® FEE
e artmgnt. / WATER CLOSET dd LOCALITY Temple Cit
Dat 'CE Z Applicant _ ►/-t:�+/�-® NEAREST Rowland
BATH TUB CROSS ST. -_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 2 SHOWER IOW.NER J. B. Weber Const. Co., Inc.
4 LAVATORY MAIL
(This section need not be completed if the work involved ADDFIEss5926 Temple City Blvd.
by the permit is for one hundred dollars ($100) or less.) 2 SINKlit
CITY Temple City TEL.N0.286-2818
I certify that in the performance of the work for which this 2 DISHWASHER V
permit is issued, I shall not employ any person in any manner _4
CONTRACTOR OLIVAS BROS. PLUMBING CO.
so as to become subject to the Workers'Compensation Laws. 2 CLOTHES WASHER ADDRESS 414 W. .California Street 0
Date Applicant �, SWIMMING POOL RECEPTOR
,NOTICE TO APPLICANT: If, after making this Certificate of ;i CITY Ontario TEL.NO.984-5069
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM CL
Compensation provisions of the Labor Code,you must forth- 2 WATER HEATER LICENSE NO. 415541 CLASS C-36 Cl)
with comply with such provisions or this permit shall be
deemed revoked. 2 GAS SYSTEM 8 OUTLETS DISTRICT NO. P OCE$SED B
LICENSED CONTRACTORSDECLARATION OUTLETS OVER S-1 64P
I hereby affirm that I am.licensed under provisions of Chapter 6 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINALQ -� VALIDATION
ness and Professions Code, and my license is in full force and DATE
effect.
415541 C-36 FINAL
License Number tic.Class- - - BY V
Contractor
Plumbing Da
10-582
te 6�
I am exempt from the licensing requirements as I am a '.Plan check fee �ds
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
tic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby'affirm that I am exempt from. the Contractor's Address
License Law for the following reason (Section.7031.5, Busi- :I City Tel.No. I z.,b 6 2 a
Hess and Professions Code):
`.o00aa5
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project 2'-
o 9 6 5 0
(Section 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY o 0 09650
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is a 0 5—8 2
issued(Sec.3097.,Civ.C.).
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above- 'one propert .for'nspection purposes.
Signature of Permittee Date