HomeMy Public PortalAbout4845 ARDEN DR_Plumbing__ WlJRKERS'`COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
-~I heieby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure;,or a certificate of Workers' Compensation Insurance, 76A667A
ora certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
0• Certified copy is hereby furnished.
aFOR 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 Appligant 3 WATER CLOSET , 4�?; �Q NEAREST
BATHTUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' 2 � DO -
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less.) ., LAVATORY O �� MAIL �
• ADDRESS b�Dpp�'� •V � I7 (7`+�+
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner I SINK D' CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHERc
CONTRACTOR � ` . -e X90
Date Applicant �� CLOTHES WASHER f U L
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS (�z
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL. NO.W 3
Compensation provisions of the Labor Code, you must forth- ` �� 9
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE ll� yA LIC.
deemed revoked. WATER HEATER c p LICENSE NO. J 1 ` CLASS ?10
LICENSED CONTRACTORS DECLARATION b �'� DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM S OUTLETS ��
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and m license is in full force and effect. 5 PER SYSTEM 3'
S3—1 my
VALIDATION
�,( Z � DATE Z
(�-97
License Number J 1 Lic. Class
'� 90 FINAL X
Contractor — Date BY
I am exempt under Sec. U
sD LU
B.&P.C. for this reason Plan check fee
N
Date: �
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE Or
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name 1-:i•.)
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address �R� iso",
Professions Code): City Tel. No.El "
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
L::3k
I hereby affirm that there is a construction lending agency for i.kN
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name f'}• ` F_3>' _ '.'� _
'_S ti '!•4i 3 i c C�l
Lender's Address Q. .`:_
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
0-1
Signature of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1307100038
BUILDING AND SAFETY j LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: FEES PAID I BUILDING ADDRESS:
IBK: 244 PG: 67 PC: 1 4 1 4845 ARDEN DR
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917804054
ASSESSOR INFORMATION NUMBER: I INEAREST CROSS STREET: LOWER AZUSA 1
18585-015-076 101 PERMIT ISSUANCE FEE 27.80 1 THOMAS PAGE: 597 GRID: B5 LOCALITY: TEMPLE CITY CAI
1 125 LAVATORIES/SINKS 1.00 FIX 16.20 J_
(TENANT: I TOTAL FEES 44.00 (ISSUED ON: PROCESSED BY: PLAN BY: I
107/10/13 SR
I
(OWNER: TEL. NO: IF AL DATE FIVJi BY: CODE:
IMEKS4845 ARD DARA (626) 277-8693-
4845 ARDEN DR r �11a✓
ITEMP 917804054 IDESCRIPTION OF WORK 1
REPLACE KITCHEN SINK
(APPLICANT: TEL. NO:
SAME AS OWNER - 1
I (SPECIAL CONDITIONS:
I I I I
(CONTRACTOR: TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER - 1
LIC. NO (UNDER SLAB WORK I1
I I
IWATER SERVICE
(PLASTIC YIN METAL YIN 1
ARCHITECT OR ENGINEER: .TEL. NO:
- 1 TROUGH PLUMBING 1
LIC. NO: 1 1
IGAS PIPING I1
I �
IGAS VENT I1
IHOT WATER HEATER
(PLUMBING FIXTURES 1
I I I
I
(LAWN SPRINKLERS I I
IGAS TEST 1
I (UTILITY COMPANY NOTIFIEDI I I
ICWV 1 I
I
( (GRAY WATER SYSTEM 1
I
I I I I 11
I i I I i I
I I I I I I
I I I I I I
I I I I I I
IREPORT ID: DPR263 ROUTE TO: BS0508