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Home My Public Portal About6116 AVON AVE_Plumbing__ WORKERS COMPENSATION DECLARATION 76A867A by affirm that r_ha ..e certificate of consent to self CE 817 (7 60 ) APPLICATION FOR PLUMBING PERMIT r a certificate of Workers Compensation Insurance or red copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ❑ ADDRESS Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM ! FEE department LOCALITY WATER CLOSET Date Applicant 4 NEAREST 67 t BATH TUB CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved LAVATORY MAILADDRESSa. by the permit is for one hundred dollars ($100) or less) SINKTEL N0 CITY O�id V I certify that in the performance of the work for which this DISHWASHER permit is issued I shall not employ any person in any manner CONTRACTOR so as o beco e s bject to the grkers Compensation s CLOTHES WASHER �J dd}• ADDRESS Date�Applicant .. SWIMMING POOL RECEPTOR ;34Y NOTICE TO AP LICANT If after making this Certificate of CITY TEL NO Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM Compensation provisions of the Labor Code you must forth STATE LIC WATER HEATER TA. LICENSE NO .� �1 CLASS with comply with such provisions or this permit shall be DISTRICT NO PROCESSED deemed revoked GAS SYSTEM L OUTLETS LICENSED CONTRACTORS DECLARATION �` OUTLETS OVER I hereby affirm'that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi FINAL VALIDATION ness and Professions Code and my license is in full force and DATE +a effect _ FINAL Liciense Number Lic Class BY Contractk &,2 &� { Date �a F1I am exempt from the licensing requirements as I am a Plan check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051 Bus mess and Professions Code) TOTAL FEE Lic or Reg No Date Plan check applicant HOME OWNER BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractors Address 1 Q 3,4 A License Law for the following reason (Section 7031 5 Busi City Tel No ness and Professions Code) #8 o ro o 0 o 5 , ElI as owner of the property am exclusively contracting _ 2 0 - 4050 with licensed contractors to construct the project I (Section 7044 Business and Professions Code) o a o 4 05 OCT_ CONSTRUCTION LENDING AGENCY 0612-84 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 SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing and hereby autha repres atives of this County to enter upon the S�qg<% enperty for inspection purposes a-4/�f ermitteeDate t e WORKERS°COMPENSATION DECLARATION APPLICATION FOR, PLUMBING PERMIT , k hereby ttlh '%at I have a certificate of consent to self in 76A66�A PW 4/ 87 e sure or a certificate of Workers Compensation Insurance or;a CE 817(REV 8/86) ` ` f - ^� certified copy thereof (Sec 3800 Lab C )' r I b E , 4 +� y Y t COUNTY OF LOS ANGELES J ` DEPT-' OF PUBLIC WORKS Policy Nor Company - .t t w a ❑ Certified copy,,is hereby furnished v r`FOR'rAPPLICANT TO FILL IN(PRINT OR TYPE) BUILDING T e Certified copy is flied with the county building inspection ADDRESS 2 G department �� f r w eaa g e + J NUMBER *FIXTURE OR ITEM y Cal FEE a LOCALITY a V 1n t �� z r WATER CLOSET(TOILET) s m vp Date Applicant + r NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS a z BATH TUB s' Y V CROSS Sr ` _ COMPENSATION INSURANCESHOWER _ f OWNER`° r (This section need not be completed if thefwork involved by - A'the permit is for one hundred dollars ($100) o`r less )r a ,LAVATORY, a a ADDRESS I certify that-inythe performance of the work for which this per mit is issued I shall,not employ any-person SINK erson in any manner so ' �c CITY - i� TEL NO } as to becomet subject to the Workers Compensation Laws DISHWASHER r ' CONTRACTOR Dat'�e t r Applicant CLOTHES WASHER ` NOTIC O APPL CANT If after making this Certificate of Ex _ v ADDRESS emptio ,yohould become subject to the Workers Compen SWIMMING POOL RECEPTOR n uls q r _ CITY .e ,`l TEL NOg'/ ,,,g/ sahon provisions of�the Labor Code'you must forthwith comp LAWN SPRINKLER SYSTEM + r " r 4d'r/ ly with such provisions or this permit sholl�be deemed revok STATE LIC ed 'r , - I " WATER HEATER ' ^ 1 LICENSE NO CLASS " LICENSED CONTRACTORS DECLARATION GAS SYSTEM F DISTRICT NO RO SE Y 11 I hereby affirm that I am licensed under provisions of ChapOUTLETS,ter " 9(commencing with Section 7000)of Division 37of the Businesst' OUTLETS OVER q a, y and Professions Code and my license is in full force and of _ 5iPER SYSTEM FINAL feet } a h L a e" r a` "` DATE VALIDATION a t License'Number Lir (-loss lyss r y 1 U t. ' c T G / ��v _ ` FINAL y p Co'ntractor Date b BY O I am'exempt under c W B &P C'for this reason _ ro Plan check fee - -'- , r - N> rs t v e a D r PLUMBING PERMIT ISSUING FEE$ S Signature �'^ -�I o o TOTAL FEE 13 a ' SINGLE FAMILY °j r HOME OWNER BUILDER DECLARATION Plan checkrapplicant 4 F I hereby affirm that I am exempt from the Contractor s License Name Law for the following reason (Section 7031 5 Business and Professions Code) , Address ' ACCT.ir, It as owner of the property"will do"the'work and the 1 City r Tel No _ �,�t/7 x 64.50 y structure is not i„tended or offered for sale(Section 7044 r r - �_ ,r a M N 1 ITEMS i Business and Professions Code) ^ _ b s x r F i + jr r l +.rr + Tt1TAL 34 x,50 � ^ CONSTRUCTION LENDING AGENCY - � y , ' Y L f � � T 4 I hereby affirrm that there is the performance of then wa construction lending agency for F R f ' CHECK -1* T r ork forywh*ch this permit is issued 4 r �t�-� (Sec,3097 'Civ^C ) a d 2ti; { h * s a c CHAD .� Lender"s Name f �' ' J " D �1_ /�-��yyyy-0001 ��yy��{yy [/28/0.9 - Lender s Addressg _ - t H t I certify that I have read this'application and state that the �, 4217 1 AM 8:21 above information is corre"ct 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 mecaned property ford in ection pur oses SEE REVERSE FOR EXPLANATORY LANGUAGE - Y Signature of Permittee 6ote k COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1106130003 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE (626) 285 0488 EXT ILEGAL ID FEES PAID BUILDING ADDRESS ITR 5903 LT 49 6116 AVON AV I IFEE DESCRIPTION QUANTITY UOM AMOUNT SGAB CA 917752606 ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET 15386 009 042 101 PERMIT ISSUANCE FEE 27 80 THOMAS PAGE 596 GRID G2 LOCALITY TEMPLE CITY Cl I 107 BATHTUBS/SHOWERS 1 00 FIX 16 30 TENANT 125 LAVATORIES/SINKS 1 00 FIX 16 30 JISSUED ON PROCESSED BY PLAN BY 145 WATER CLOSET/URINAL 1 00 FIX 16 30 106/13/11 SR I TOTAL FEES 76 70 1 (OWNER TEL NO I 1FI AL DATE FINAL BY CODE INGUYEN KIM (818) 749 8063 1 I 16116 AVON AV I -ISGAB-917752606 _ I DttCTZIPTION OF WORK (REPLACE BATHTUB/SHOWER 4ATORIE AND WATER CLOSET (APPLICANT TEL NO SAME AS OWNER I ISPECIAL CONDITIONS CONTRACTOR TEL NO (APPROVALS DATE INSPECTOR SIGNATURE 1 SAME AS OWNER I I LIC NO 1UNDER SLAB WORK WATER SERVICE 1PLASTIC Y/N METAL Y/N ARCHITECT OR ENGINEER TEL NO I I IROUGH PLUMBING LIC NO IGAS PIPING I I 1 IGAS VENT I I 1 IHOT WATER HEATER I 1 IPLUMBING FIXTURES I I ILAWN SPRINKLERS IGAS TEST I I (UTILITY COMPANY NOTIFIEDI II I 1CWV I I IGRAY WATER SYSTEM I I 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 I I I I I I