HomeMy Public PortalAbout5446 BALDWIN AVE_Plumbing__ (2) .;.WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT {�
7 ♦ herasv affirm that I have a certificate of consent to self 76A667A L1
t moire`dr&certificate of Workers Compensation Insurance CE 817(REV 10/81)
or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No 22 6 ompany A�-FN� I '
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING � /
Certified copy is filed with the co u n n ADDRESS
tion depa tment ` UMBER FIXTURE OR ITEM @ FEE LOCALITY
Date a Applicant (JLC WATER CLOSET NEAREST
CE IFICATE OF EXEMPTION FROM ORKERS BATH TUB Lr6 CROSS ST
COMPENSATION INSURANCE SHOWER QU OWNER �� �� �ANb (i6
(This section need not be completed if the work involved by MAIL
0the permit is for one hundred dollars ($100)or less ) LAVATORY 2 0 ADDRESS
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK 6 O O CITY TEL NO
so as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR C A Zof
i �
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT If after making this Certificate of ADDRESS ** 0
Exemption you should become subject to the Workers .ry SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM CITY TEL N /g96 ��
with comply with such provisions or this permit shall be STATE C!I � IC �^
deemed revoked WATER HEATER OJI LICENSE NO CLASS c✓�JC7
LICENSED CONTRACTORS DECLARATION DISTR��3.�O ,/ �t ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 j GAS SYSTEM OUTLETS 0 (/Y f
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER O
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINALVALI TION
DATE �117
Off.
License Number I go Lic Class O
1!�A& )`AC FINA U
Contractor/-29A&;9 Date BY
0.'
❑ 1 am exempt under Sec
;94998A U
B &P C for this reason , W
Date Plan check fee , # o o o ci o 5 N
PLUMBING PERMIT ISSUING FEE$ Z
Signature
TOTAL FEE 1 — 8250
Plan check applicant =
SINGLE FAMILY o 0 0 8 2 5 Q v
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License Address 07
10-86 0686
Law for the following reason (Section 7031 5 Business and
Professions Code) Cit Tel No
❑ Y
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)
CONSTRUCTION LENDING AGENCY yf+
I hereby affirm that there is a construction lending agency for 1
the performance of the work for which this permit is issued
(Sec 3097 Civ C ) '
Lender s Name
Lender s Address
i
I certify that I have read this application and state that the f
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 mento e pro rt or ins coon purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
gn t re o itt a D e I
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0306030006
• BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285 0488 EXT
-LEGALFEES PAID BUILDINGADDRESS
BK 187 PG 50 PC 1 5446 BALDWIN AV
FEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917802624
ASSESSOR INFORMATIONNEAREST CROSS STREET DAINES
8586-023 028 01 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 597 GRID B4 LOCALITY TEMPLE CITY
51 LOW PRS GAS 5 OUTLET 1 00 SYS 16 20
TENANT 64 WATER PIPNG - 1 1/2 1 00 LIN 16 20 S E NEXPIRES
TOTAL FEES 60 15 06/03/03 JK 11/30/03
OWNER TEL NO FINAL DATE FINAL BY CODE
PETZHOLT RAYMOND P & ANNIE A (626) 575 4950 ��Z��tl
5446 BALDWIN AV
TEMP 917802624C TPION OF WORK
GASLINE FOR BBQ AREA, WATER LINE FOR WATERFALL
APPLICANT TEL NO
SAME AS OWNER
SPECIAL CONDITIONS
CONTRACTOR TEL NO APPROVALS DATE INSPEC GNATURE
SAME AS OWNER
LIC NO UNDER SLAB WORK
WATER SERVIC
f J' PLASTIC Y/N METAL Y/N
ARCHITECT 0 --- �
ROUGH PLUMBING
LIC NO � � _ _
GAS PIPING
i
73 B 7-/a a3
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES
LAWN SPRINKLERS
GAS TEST
UTILITY COMPANY NO ED
WV
GRAY WATER SYSTEM
REPORT ID DPR263 ROUTE TO BS0508