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HomeMy Public PortalAbout10792 BLACKLEY ST_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of.Workers' Compensation Insurance, CE 817(REV 10/81) or a certified copy thereof (Sec 380 ,)Lab ) COUNTY OF LOS ANGELES BUILDING ANDS FETY Policy No Compon Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING - Certified copy is filed_with the cou ty building inspec- ADDRESS tion di ---- - _ __ _ _NUMBER FIXTURE OR ITEM r FEE e arment. -`f�{�J — LOCALITY Date./6 APPlicanHY� Y Dn - WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' 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 $100 or less. MAIL P ( ) ) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL NO so as to become subject to the Workers'Compensation Laws DISHWASHER DJ!/J'— CONTRACTOR i `'� Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth-" CITY TEL NO. 1 LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE > LIC. deemed revoked WATER HEATER LICENSE NO / CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS , n ©��� (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER l/ and Professions Code,and my license is in full force and effect 5 PER SYSTEM_ FINAL fL DATE O —,27 � VALIDATION V License Nu ber Lic. Class FINAL Contracto Ate'. � ,l,� BY S_././- �`_..t" 9-•-�e.._q.,a �s J; V �� � � o ❑ I am exempt under Sec. / �� BAP C for this reason 7X6 / (A Plan check fee 5 Signatu ZEFID Date �//, PLUMBING PERMIT ISSUING FEE$ V TOTAL FEE Plan check applicant /6 l(, SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name / �� I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031 5, Business and Professions Code)- City Tel No. ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale Section � !^ori qq?� - �J�y 7044, Business and Professions Code) �tLI CONSTRUCTION LENDING AGENCY ari�4u� j 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 authorize representatives of this County to enter upon the above-mentioned prop6rty 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 0201240012 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: TR: 13613 LT: 53 10792 BLACKLEY ST FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803501 _ ASSESSOR_IN-ORMAT-ION-N BER: NEAREST CROSS STREET: MCCULLOCH -8573-006-007 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597- GRID: D3 LOCALITY: TEMPLE CITY 07 BATHTUBS/SHOWERS 1.00 FIX 16.20 TENANT: 25 LAVATORIES/SINKS 1.00 FIX 16.20 ISSUED 0 PROCESSED BY: PLA BY: EXPIRES ON: 45 WATER CLOSET/URINAL 1.00 FIX 16.20 01/24/02 JK 07/23/02 TOTAL FEES 76.35 • OWNER: TEL. N0: FINAL DTE FINAL BY: CODE: LU;JING DIANG (626) 279-2022- 10792 BLACKLEY ST ` TEMP 917803501 DESCRIPTION OF WORK NEW BATHROOM PPLICANT: L. 0: SAME AS OWNER SPECIAL CONDITIONS: CONTRACTOR: TEL. N0: APPROVALS DATE INSPECTOR SIGNATURE SAME AS OWNER - LIC. NO- UN ER_SL* -WORK pU G WATER SERVICE PLASTIC Y/N METAL Y/N ARCHITECT OR ENGINEER: TEL. NO: ;I ROUGH PLUMBING LIC. N0: i I GAS PIPING GAS VENT HOT WATER HEATER PLUMBING FIXTURES LAWN SPRINKLERS GAS TEST .,; UTILITY COMPANY NOTIFIED CWV GRAY WATER SYSTEM REPORT ID: DPR263 ROUTE TO: SS0508 ` COUNTY OF LOS ANGELES' TEMPLE CITY # 0508 PLUMBING PERMIT , DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0904130004 BUILDING AND SAFETY /LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT. LEGAL ID: FEES PAID BUILDING ADDRESS. - ITR: 13613 LT: 53 - 10792 BLACKLEY ST - IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803501 ASSESSOR INFORMATION NUMBER: I NEAREST CROSS STREET: 18573-006-007 101 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: D3 LOCALITY: TEMPLE CITY, Cl I 107 BATHTUBS/SHOWERS 2.00 FIX 32.40 I TENANT: 111 CLOTHESWASHER(S) 1.00 FIX 16.20 JISSUED ON- PROCESSED BY- PLAN BY: EXPIRES ON I 121 HOSE BIBB(S) 1.00 FIX 16.20 104/13/09 SR 10/10/09 I 125 LAVATORIES/SINKS 2.00 FIX 32.40 1 1 OWNER: TEL. N0: 145 WATER CLOSET/URINAL 2.00 FIX 32.40 1F AL DAT.Z FI Y: CODE: ILU, JING H (626) 329-8897- 147 WATER HEATER(S) 1.00 WTH 16.20 1 110792 BLACKLEY ST 151 LOW PRS GAS 5 OUTLET - 1.-0o SYS 16.20 1 1 TEMP 917803501 1 TOTAL, FEES 189.75 IDEXCRIPTIOP OF WORK IPLUMBING FOR BATHROOMS AND LAUNDRY (APPLICANT: TEL. NO: 1 ILU (626) 329-8897- 110792 BLACKLEY ST I ISPECIAL CONDITIONS: 1 ITEMPLE CITY CA 91780 1 ICONTRACTOR: TEL. NO: I _ - 1APPROVALS DATE INSPECTOR SIGNATURE IK.Y.M. CONSTRUCTION, INC. (626) 575-0843- 1 1 IDBA TAI HEATING & AIR CONDITIO LIC. NO I 1UNDER SLAB WORK / 19625 ALPACA STREET 747508BC10 I I IS. EL MONTE CA 91733 1 IWATER SERVICE I I IPLASTIC YIN METAL YIN - 1 (ARCHITECT OR ENGINEER: TEL. NO: I - I I AI I ISKUNDRIC, LAZAR - (949) 347-0062- 1 IROUGH PLUMBING I 1 128052 CAMINO CAPISTRANO LIC. NO: I I I I ILAGUNA NIGUEL, CA 92677 C35903 I IGAS PIPING 1 1 I I I I I I I I IGAS VENT I I I 1 I 1-1 1 I IHOT WATER HEATER I I 1 1 I -1-1 I I I IPLUMBING FIXTURES I 1 I I I I I I I I ILAWN SPRINKLERS I I I 1 I I GAS TEST I I I I I I I (UTILITY COMPANY NOTIFIEDI I I I I I 11 1 I I ICWV I 1 I I I I I I I I IGRAY WATER SYSTEM I 1 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 I I I I I I I I I I 1 IREPORT ID: DPR263 ROUTE TO: BS0508 1 1 1 1 I I I I I I