HomeMy Public PortalAbout4841 ARDEN DR_Plumbing__ WORKERS',COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT JJ��
.�.i hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure,,4r a certificate of Workers' Compensation Insurance, 76A667A IUI
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 ✓7' /!
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY '-
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' Z BATH TUB / �� CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars $100 or less. MAIL
p ( ) ) � LAVATORY �jLy ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
f� � � CONTRACTOR
Date S " ` °Applicant �^ —` CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 3 l/ r'
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY ` TEL. NO. "�
Compensation provisions of the labor Code, you must forth- d LAWN SPRINKLER SYSTEM ��
with comply with such provisions or this permit shall be —T STATE CJ� t^� LIC. 2
deemed revoked. ( WATER HEATER f/' LICENSE NO. CLASS �' 7
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER d
and Professions Code,and my license is in full force and effect. 5 PER�SYSTEM �
} L } Z ✓��Q D FINAL / / `� VALIDAT9OIV
0.1
DATE �'
License Number S Lic. Class C" Q.
G FINAL
Contractor _ Date ' BY
❑ I am exempt under Sec. 8�
B.&P.C. for this reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$ 3 O'o
Signature
TOTAL FEE OO
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and Address
Professions Code): City Tel. No, �•')i; •'°_FI'_3
❑ I, as owner of the property, will do the work and the i Tr'P'._:
structure is not intended or offered for sale (Section
7044, Business and Professions Code). ® ;(€ FL �� F`�€f
3 � a-.�=_
CONSTRUCTION LENDING AGENCY ;HEC*•} _
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued jY . h ,9t
(Sec. 3097, Civ. C.).
Lender's Name - ;;ii :ty f,-•;,,
Lender's Address z
I certify that I have read this application and state that the ® ` Hit1
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
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
-
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1203140026
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS: I
1BK: 244 PG: 87 PC: 1 2 1 1 4841 ARDEN DR 1
I .IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( TEMP CA 917804054 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
18585-015-074 101 PERMIT ISSUANCE FEE 27.80 1 THOMAS PAGE: 597 GRID: B5 LOCALITY: TEMPLE CITY, Cl
1 147 WATER HEATER(S) 1.00 WTH 16.20 1 1
(TENANT: I TOTAL FEES 44.00 11SSUED ON: PROCESSED BY: PLAN BY: 1
1 1 103/14/12 SR
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(OWNER: TEL. NO: i IFINAL ATE FI3AI, BY: CODE:
1JAIME T;FLORENCE F rr /
14848 (/
41 ARDEN DR I I V i I
ITEMP 917804054 I DK RIPtION OF WORK
I 1 IREMOVE/REPLACE GAS WATER HEATER 38 GAL/.60 -FT IN UTILITY
I
I (CLOSET I
(APPLICANT: TEL. NO: I I I
IMARTINEZ, NICK (323) 440-2069- I 1
112601 132 ND AVE I ISPECIAL CONDITIONS:
IKIRKLAND WA 98034 1 I
ICONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE I
IFAST WATER HEATER CO. (425) 636-7054- 1 1-
112601 132ND ST. LIC. NO (UNDER SLAB WORK I I
IKIRKLAND WA 98034 C36931237 I I I I
WAT3R SERVICE I I I
I I IPLASTIC Y/N METAL Y/N 1 I
1ARCHITECT OR ENGINEER: TEL. NO: 1 I I I
- 1 IROUGH PLUMBING I II
LIC. NO:
I GAS' PIPING I I
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IGAS VENTI I I
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!HOT WATER HEATER
IPLUMBING FIXTURES 1 1 I
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I 1 ILAWN SPRINKLERS 1 1
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IGAS TEST
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(UTILITY COMPANY NOTIFIED( II
I 1 Com_ I
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I I IGRAY WATER SYSTEM I I I
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!REPORT ID: DPR263 ROUTE TO: BS0508
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