HomeMy Public PortalAbout4843 ARDEN DR_Plumbing__ WORKERS'QOMPtNSATION DECLARATION APPLICATION FOR,PLUMBING PERMIT
.hereby''affirm that I have a certificate'of consent to self 20-0026 DPW 6/87 I
insure, or a'certificate of Workers' Compensation Insurance, 76A667A ILJI
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy No. Company
• BUILDING
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM a FEE LOCALITY
Date Applicant WATER CLOSET So NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' Z BATH TUB j� CROSS ST.
COMPENSATION INSURANCE OWNERC�JZM
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars($100)or less.) LAVATORY MAIL
Q �� ADDRESS
I certify that in the performance of the work for which This
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
�/ J CONTRACTOR
Date ✓'� Applicantj+ CLOTHES WASHER ADDRESS l�Z 1
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITYp� TEL. NO.SU 3n-51 J
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM r sr
with comply with such provisions or this permit shall be STATE �3-1 ( CLASS
deemed revoked. WATER HEATER LICENSE NO. ii
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM 5 OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and m license is in full force and effect. 5 PER SYSTEM ?�
Y t FINAL VALIDATION
DATE0.
License Number }\ Lic. Class —�� U.
FINAL'
Contractor ` Date I BY
I am exempt under Sec.
B.&P.C. for This reason Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License F;a i o=;•.
Law for the following reason (Section 7031.5, Business and Address _
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the ) 3
structure is not intended or offered for sale (Section
7044, Business and Professions Code). ® ''FUl ktiL 16Z m .100
CONSTRUCTION LENDING AGENCY _ L E.` "a"1
ty... .t.__n_?_+
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued ';; '
i��Et.�` 7 i;F t
(Sec. 3097, Civ. C.).
Lender's Name r S-; _bf•-;
Lender's Address 4 L;' si •
I certify that I have read this application and state that the ® "-"' - til;I
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.
— n'I 2_6�� I
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee 7f Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1309260006
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS: 1
IBK: 244 PG: 87 PC: 1 3 I I 4843 ARDEN DR 1
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA 917804054
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: LOWER AZUSA 1
18585-015-075 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 597 GRID: B5 LOCALITY: TEMPLE CITY CAI
1 107 BATHTUBS/SHOWERS 2.00 FIX 32.40 1
(TENANT: 125 LAVATORIES/SINKS 2.00 FIX 32.40 11SSUED ON: PROCESSED BY: PLAN BY:
I 145 WATER CLOSET/URINAL 2.00 FIX 32.40 109/26/13 SR
I I TOTAL FEES 125.00 1
1OWNER: TEL. NO: 1 I FINALR ATTR/E FI"!j��/PJS�'XYaJY: CODE: 1
TU, JOEY (626) 6`72-8240- I
4843 ARDEN DR II�
ITEMP 917804054 1 DffAAIPTION OF WORK
REPLACE BATHTUBS/SHOWERS, LAVATORIES AND WATER CLOSETS
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1APPLICANT: TEL. NO: 1 I 1
ISAME AS OWNER -
I I ISPECIAL CONDITIONS: 1
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(CONTRACTOR: TEL. N0: j 1APPROVALS DATE INSPECTOR SIGNATURE
ISAME AS OWNER -
1 LIC. NO (UNDER SLAB WORK
I I IWATEP SERVICE
I IPLASTIC Y/N METAL Y/N I I
(ARCHITECT OR ENGINEER: TEL. NO: I
- j IROUGH PLUMBING
LIC. NO: �
I IGAS PIPING
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IHOT WATER HEATER
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I (GRAY WATER SYSTEM 1 1
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IREPORT ID: DPR263 ROUTE TO: BS0508
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