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HomeMy Public PortalAbout5837 AGNES AVE_Plumbing__ -7 WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT r1,her'eb� affirm that I have a certificate of consent to self 20 0026 DPW 6/87 inSL;re or a certificate of Workers Compensation Insurance 76A667A or 6 certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS Policy Nb Company ❑ Certified copy is hereby furnished w _ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �t k 17 Certified copy is filed with the county building inspec ADDRESS L= tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY F WATER CLOSET Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST COMPENSATION INSURANCESHOWER QO OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less ) LAVATORY lzo_ QQ ADDRESSL I certify that in the performance of the work for which this permit is issued I shall not employ any person in any manner SINK CITY _ , TEL NO so as to become Subject to the Workers Compensation Laws DISHWASHER CONTRACTOR Dat & Applicant`J� CLOTHES WASHER ADDRESS NOTICE TO APPLICANT If after making this Certificate of Exemption you should become-subject to the Workers SWIMMING POOL RECEPTOR CITY TEL NO Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be Q STATE LIC deemed revoked WATER HEATER LICENSE NO CLASS LICENSED CONTRACTORS DECLARATION �O DISTRICT NO P E D BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS � (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER J/ © and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL :� VALIDATION Ol DATE �r License Number Lic Class / U FINO� `, IJP Contractor Date BY k c7, ❑ I am exempt under Sec ,465 � 0 B 8P C for this reason Plan check fee } Date PLUMBING PERMIT ISSUING FEE$ Q Z Signature TOTAL FEE SINGLE FAMILY Plan check applicant a HOME OWNER BUILDER DECLARATION Name Af-VIC-1 ACCT.V I hereby affirm that I am exempt from the Contractor s License .V Law for the following reason (Section 7031 5 Business and 11 Address S' �,07 ?off Pro ssions Code) City �z� Ger Tel No 6 1 ITEM I as owner of the property will do the work and the structure is not intended or offered for sale (Section TOTAL 52 n 51131 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY CHECK 52.5rl I hereby affirm that there is a construction lending agency for � � n the performance of the work for which this permit is issued 00 (Sec 3097 Civ C ) L Lender s Name 0000-0001 6/26/.n Lender s Address 4178 1 AM 9:17 j 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 authorize representatives of this County to enter upon the abo a mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0901280004 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE (626) 285 0488 EXT ILEGAL ID FEES PAID BUILDING ADDRESS ITR 6561 LT 436 5837 AGNES AV 1 I IFEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917802216 (ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET LAS TUNAS 1 18587 027 009 101 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 597 GRID A3 LOCALITY TEMPLE CITY CI 107 BATHTUBS/SHOWERS 1 00 FIX 16 20 1 TENANT Ill CLOTHESWASHER(S) 1 00 FIX 16 20 JISSUED ON PROCESSED BY PLAN BY EXPIRES ON 1 121 HOSE BIBB(S) 2 00 FIX 32 40 101/28/09 SR 07/27/09 1 125 LAVATORIES/SINKS 2 00 FIX 32 40 1 1OWNER TEL NO 145 WATER CLOSET/URINAL 1 00 FIX 16 20 IFINAL DATE FIKAL BY CODE ICHEN MR & MRS 147 WATER HEATER(S) 1 00 WTH 16 20 1 �� 1 15837 AGNES AV 151 LOW PRS GAS 5 OUTLET 1 00 SYS 16 20 ITEMP 917802216 I TOTAL FEES 173 55 I15ESC IPTI N OF WORK IPLUMBING FOR ADDITION (APPLICANT TEL NO I I 1 IO LEARY . (626) 287 0927 I 1 15823 AGNES AVENUE ISPECIAL CONDITIONS ITEMPLE CITY CA 91780 1 I I I (CONTRACTOR TEL NO 1 1APPRCJALS DATE INSPECTOR SIGNATURE 1 (TOM 0 LEARY CONSTRUCTION (626) 287 0927 1 1 15823 AGNES AVENUE LIC NO 1UNDER SLAB WORK I ITEMPLE CITY CA 91780 489354 B 1 1 1 I I I I IWATER SERVICE I I I IPLASTIC Y/N METAL Y/N I I I 1ARCHITECT OR ENGINEER TEL NO 1 1 IROUGH PLUMBING �1 I LIC NO 1 I I I I IGAS PIPING IGAS VENT I 1 IHOT WATER HEATER IPLUMBING FIXTURES I I I ILAWN SPRINKLERS 1 I I 1 I IGAS TEST I I 1UTILITY COMPANY NOTIFIEDI I I 1 ICWV 1 I IGRAY WATER SYSTEM I I 1 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I 1 (REPORT ID DPR263 ROUTE TO BS0508 1 I I I COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ' PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0710250005 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE (626) 285 0488 EXT LEGAL ID 11 FEES PAID BUILDING ADDRESS ITR 6561 LT 436 5837 AGNES AV 1 'IFEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917802216 ASSESSOR INFORMATION NUMBER 1 NEAREST CROSS STREET LAS TUNAS _ 18587 027 009 101 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 597 GRID A3 LOCALITY TEMPLE CITY Cl 164 WATER PIPNG <= 1 1/2 1 00 LIN 16 20 1TENANT I TOTAL FEES 43 95 (ISSUED ON PROCESSED BY PLAN BY EXPIRES ON 1 1 110/25/07 SR 04/22/08 1OWNER TEL NO 1 (FINAL DtTE FIN Y CODE 1 15837 AGNES AV 1 1 i 1 1TEMP 917802216 1 CRIPTION tF WORK 1 1 1NEW WATER MAIN 1 1APPLICANT TEL NO 1 1 1MARTINEZ (626) 905 0634 1 1 1201 MURRAY AVE 1 1SPECIAL CONDITIONS IAZUSA CA 91702 1 1CONTRACTOR TEL NO _ IAPPPOVALS DATE INSPECTOR SIGNATURE 1 IISIDRO MARTINEZ (626) 905 0634 1 f 1 1201 MURRAY AVENUE LIC NO 1UNDER SLAB WORK 1 1 IAZUSA CA 91702 862091 C36 i1 SERVICE �/ 1 1 1 PLA-TIC YIN METAL YIN f 1ARCHITECT OR ENGINEER TEL NO 1 1 1 (ROU PLUMBING LIC NO 1 1 1 1GASIPIPING 1 1 1 1 1 1 GAq VENT 1 1 1 n ,L 1 1 1 �1 1HOTIWATER HEATER 1 1 1 1 IPLUMBING FIXTURES 1 1 1 1LAWh SPRINKLERS 1 I 1 1 1 1GAS TEST 1 1 1UTILITY COMPANY NOTIFIED( ICWV I I I 1 1 GRA) WATER SYSTEM 1 1 I I I I I I 1 1 � 1 1 1 r f I I I I 1 1 i 1 1 1 I I I I I i I I I I I 1 IREPORT ID DPR263 ROUTE TO BS0508 1 1 1 1 I I I I I I