Loading...
HomeMy Public PortalAbout5006 BALDWIN AVE_Plumbing__ (2) WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT ��77 I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers' Compensation Insurance, 76A667A or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS No. Company Policy Certified copy is hereby furnished. BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS tion deportment. Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Appiigant WATER CLOSET NEAREST 4/1 CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER ��CJ (This section need not be completed if the work Involved by the permit is for one hundred dollars $100 or less. MAIL P ( ) � LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL, NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NC©� SSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code, and m license is in full force and effect. 5 PER SYSTEM Y FINALDATE /� Z VALIDATION 0.1 License Number0. Lic. Class 0.. FINAL Contractor Date BY 0 ❑ I am exempt under Sec. IU B.BP.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ _ � _ Signature 5 ._...„`7 TOTAL FEE SINGLE FAMILY Plan check applicant y HOME OWNER-BUILDER DECLARATION Name 3 Vhhereb, affirm that I am exem t from the Contractor's License p Addressthe following reason (Section 7031.5, Business andns Code): City Tel. No.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). 4.4It""3}1;11 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 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 ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm tFiat I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers' Compensation Insurance, 76A667A or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No.-, Company Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed If the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS © � I certify that in the performance of the work for which this AJ SINK CITY 42 TEL. NO. /^ permit is issued, I shall not employ any person in any manner 3-ramp so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS rA (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �J V and Professions Code,and my license is in full force and effect. S PER SYSTEM FINAL VALIDATION DATE License Number Lic. Class (� FINAL Contractor Date BY n0. ' ❑ I am exempt under Sec. Ltd B.&P.C. for this reason ILI Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature 7_4�] TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name t^1^_'i•_. e I hereby affirm that I am exempt from the Contractor's License Address I :? Law for the following reason (Section 7031.5, Business and Prof ssions 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). CHECK CONSTRUCTION LENDING AGENCY -.,1n;. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name -j il4'n -i-- 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 authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE t Signature of Permitt Date COUNTY OF LOS ANGELES TEMPLE CITY # 0508 - PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0205140007 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE (626) 285 0488 EXT LEGALD G ADDRESS ON FILE 5006 BALDWIN AV FEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917804010 ASSESSOR INFORMATION NUM8 NEAREST CROSS STREET LA ROSA 8585 008 013 01 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 597 GRID B4 LOCALITY TEMPLE CITY _ 07 BATHTUBS/SHOWERS 1 00 FIX 16 20 TENANT 25 LAVATORIES/SINKS 1 00 FIX 16 20 ISSUED ON PROCESSED BY PL RES ON 45 WATER CLOSET/URINAL 1 00 FIX 16 20 05/14/02 JK 11/10/02 TOTAL FEES 76 35 OWNER TEL NO FINAL DATE FINAL BY CODE VINH P LU,PHUONG T HUYNH (626) 443 9642 11537 CHERRYLEE DR ®�/Z EL MONTE 91732 DOCR LUMBING FOR ADDITION/REMODEL APPLICANT TEL NO HIEN NGUYEN (626) 614 8165 5219 ACACIA ST SPECIAL CONDITIONS SAN GABRIEL 91776 CONTRACTOR TEL NO %� ' AFPROVALS DATE INSPECTOR SIGNATURE EG BUILDER (626) 614 8165 5219 ACACIA ST LIC NO ��"- ✓ ��\ DE SLAB WORK SAN GABRIEL, CA 91776 746346 L WATER RSERVICEPLASTIC Y/N METAL Y/N CH R TEL !� I� �� �� \ OUGH PLUMBING L I C NO ; --I-� 1 r � ' I 11 �` GAS PIPINGAS VENT \ - AOT WATERHEATER Z PLUMBING-FrUMS ` LAWN SPRINKLERS I r / GAS TEST -ILITY C OMPANY NOTIFIEU Z C V - Z GRAY WATER SYSTEM REPORT ID DPR263 ROUTE TO BS0508 COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT ' DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0807020004 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE (626) 285 0488 EXT (LEGAL ID I FEES PAID I BUILDING ADDRESS ON FILE I 1 5006 BALDWIN AV 1 IFEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917804010 1 (ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET 1 18585 008 013 101 PERMIT ISSUANCE FEE 27 75 I THOMAS PAGE 597 GRID B4 LOCALITY TEMPLE CITY Cl 107 BATHTUBS/SHOWERS 1 00 FIX 16 20 1 I ITENANT 125 LAVATORIES/SINKS 1 00 FIX 16 20 (ISSUED ON PROCESSED BY PLAN BY EXPIRES ON 1 TOTAL FEES 60 15 107/02/08 SR 12/29/08 1 (OWNER TEL NO IFINAL DATE FINAL BY CODE ILU VINH P (626) 322 44751 1 15006 BALDWIN AV I i ITEMP 917804010 I ID SCRIPTION OF WORK 1 it LAVATORIE AND WATER CLOSET ONLY (APPLICANT TEL NO 1 1 KHAN (626) 318 9839 1 19101 HERMOSA DR ISPECIAL CONDITIONS TEMPLE CITY CA 91780 1CONTRACTOR1 I TEL NO i (APPROVALS DATE INSPECTOR SIGNATURE I IVINH P LU (626) 443 9642 15006 BALDWIN AVENUE LIC NO 1 I1 ITEMPLE CITY CA 91780 NONE 1 1UNDER SLAB WORK I 1 I IWATER SERVICE I I I 1 IPLASTIC YIN METAL YIN 1 1 (ARCHITECT OR ENGINEER TEL NO I I LIC NO 1 TROUGH PLUMBING I I IGAS PIPING ( 1 I I IGAS VENT I 1 I (HOT WATER HEATER 1 I IPLUMBING FIXTURES I I (LAWN SPRINKLERS I I GAS TEST 1UTILITY COMPANY NOTIFIED( I I ICWv I I 1 1 GRAY WATER SYSTEM I I I I NO ak���I hl I I I I I l I I I I I I I 1 1 I I I I I I I I I I I I I _ 1REPORT ID DPR263 ROUTE TO BS0508 1 I I I I I I I