HomeMy Public PortalAbout4868 ARDSLEY DR_Plumbing__ WORKERS'COMPENSATION DECLARATION• APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consenti to self,, 76A667A
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES C BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING4k-&
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM r, FEE
LOCALITCIA
Date Applicant WATER CLOSET NEAREST -
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. L!
COMPENSATION INSURANCESHOWER OWNER t
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) /10LAVATORY ADDRESS
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK �'�� CITY`f_ TEL. NO. S�
so as to become subject to the�Wworkrs' mp nsation Laws. DISHWASHER IF
CONTRACTOR
Date � + k icaL'/l G`C/ CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL. NO.
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCESSED&Y'
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ��6*1 ,
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER V (�
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL 0
DATE _ V .'IDATION U
License Number Lic. Class 0
r,C
FINAL O
Contractor Date BY U
V
❑ LUI am exempt under Sec. IL
eil
B.&P.C. for this reason ►Date: Z
Plan check fee
PLUMBING PERMIT ISSUING FEE$ ® �7
Signature
TOTAL FEE
Plan check applicant ° •-`o'Z �'
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name % ; tr
I hereby affirm that I am exempt from the Contractor's License
L��I,
fthe following reason (Section 7031.5, Business and Address
ns Code): City Tel. No.
as owner ofthe property, will do the work and the ,
structureis not intended or offered for sale (Section.
7044, Business and Professions Code).
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
auth ize repr sentatives of this County to enter upon the
abo -mention d 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 1306120008
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 14647 LT: 39 I 4868 ARDSLEY DR
IFEE DESCRIPTION: - QUANTITY: UOM: AMOUNT: ( TEMP CA 917803801
(ASSESSOR INFORMATION NUMBER: I ' I NEAREST CROSS STREET: I
18590-016-003 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY CAI
1 163 WATER PIPING BR/FIX 10.00 FIX 68.00 I I
(TENANT: 164 WATER PIPNG <= 1 1/2 1.00 LIN 16.20 (ISSUED ON: PROCESSED BY: PLAN BY: 1
1 TOTAL FEES 112.00 106/12/13 SR 1
(OWNER: TEL. N0: 1 IF�ALATE FIN BY: CODE: I
IDUNIVEN MICHAEL L;TERI L (626) 285-5798- I 1
14868 ARDSLEY DR 1
ITEMP 917803801 1 SCRI TIO OF WORK I
I I ICOPPER/PRO PEX RE-PIPE (10 IXTURES) & 1-1" WATER SERVICE 1
(APPLICANT: TEL. NO:
IST PIERE, MARK (626) 287-7544-
15454 TEMPLE CITY BL ISPECIAL CONDITIONS:
ITEMPLE CITY CA 91780 I
ICONTRACTOR: TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE 1
ISTP ENTERPRISES, INC. (626) 287-7544- 1-
15454 TEMPLE CITY BLVD LIC. NO (UNDER SLAB WORK
I I
ITEMPLE CITY CA 91780 598157 I I
eF�ERVICE
Y N METAL YIN 1 I I
1ARCHITECT OR ENGINEER: TEL. NO:
- I IROUGH PLUMBING
LIC. No: I I
IGAS PIPING I
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I IGAS VENT I I I
1 I IHOT WATER HEATER I
IPLUMBING FIXTURES I I
I ILAWN SPRINKLERS I
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IGAS TEST I I
I I I 11 I
I (UTILITY COMPANY NOTIFIEDI I
1 11
I ICWV I I I
IGRAY WATER SYSTEM I
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I* ADDITIONAL DATA ON FILE 1 1
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IREPORT ID: DPR263 ROUTE TO: BS0508 1 1
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