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Home My Public Portal About10793 BLACKLEY ST_Plumbing__ WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9/89 APPLICATION FOR PLUMBING PERMIT 76A667A hereby affirm that ( have'a certificate of consent to self insure, or a certificate of.Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab. C.) Policy No. / Company COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. - ❑ Certified copy is hereby furnished. / ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM / Q FEE LOCALITY pate Applicant WATER CLOSET NEAREST ' CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE MAP BOOK —7 (This section need not be completed if the work involved by the I SHOWER MAP BOOK PAGE QO / PARCELQ/� permit is for one hundred dollars($100)or less.) ee OWNER F e (, t I certify that in the performance of the work for which this permit 1 LAVATORY tt v� is issued, I shall not employ any person in any manner so as toSINK MAIL become subject to the Workers'Compensation Laws. ADDRESS DISWASHER CITY 7E„^l_` LE C;' TEL.NO. Date Applicant CLOTHES WASHER 1 NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR r \t� Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ls/1 provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER tb (commencing with Section 7000) of Division 3 of the Business and STATE LIC. 0 Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS U OUTLETS OVER DISTRICTn� PROCESSED BY cc O 5 PER SYSTEM C/ CF License Number Lic.Class FINAL / V DATE �-�'Z— J VALIDATION d Contractor Date U) ❑ I am exempt under Sec. BY AL Z o B.&P.C.for this reason / Date: Plan check fee , Signature n PLUMBING PERMIT ISSUING FEE ❑ TOTAL FEE � L� Plan check applicant SINGLE FAMILY ` _......_ .. . . .. _.. — a HOME OWNER-BUILDER DECLARATION Name e m W tl� -m I hereby affirm that I am exempt from the Contractor's License Law --e},; 'Es) for the following reason (Section 7031.5, Business and Professions Address l07 G, Lrti .'r3. '�°2 Code): Q _ ... i cyr_: El Tel.No. I,as owner of the property,will do the work and the structure r i rt t� is not intended or offered for sale (Section 7044, Business TOTAL-(A3— 4 ` p9 2 and Professions Code). -- , r•s,ECK CONSTRUCTION LENDING AGENCY (.HANGE 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.) cir"C113-0001 10/ 11/ 3 Lender's Name cs (c � G 1955,, Lender's Address 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 pr'.rp ti n purpo s./J / / SEE REVERSE FOR EXPLANATORY LANGUAGE ro Signature of Permittee Date COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT f DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0209230006 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUrLDING ADDRESS: TR: 13613 LT: 88 10793 BLACKLEY ST FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803502 ASSESSOR INFORMATION NUMB : NEAREST CROSS STREET: MCCULLOCH 8573-007-016 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: D3 LOCALITY: TEMPLE CITY 13 DISHWASHERS) 1.00 FIX 16.20 TENANT: 25 LAVATORIES/SINKS 1.00 FIX 16.20 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: TOTAL FEES 60.15 09/23/02 JK 03/22/03 OWNER: TEL. N0: FINAL DATE EXPIKEUY: CODE: WINSTANLEY ERIK C;CATERINA RIZZI (626) 448-7853- 10793 BLACKLEY ST TEMP 917803502 DESCRIPTION OF. WORK REINSTALL EXISTING DISHWASHER AND SINK APPLICANT: TEL. NO: SAME AS OWNER SPECIAL CONDITIONS: CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE SAME AS OWNER - LIC. NO UNDER SLAB WORK WATER SERVICE ARCHITECT OR ENGINEER: TEL. NO: PLASTIC YIN METAL YIN LIC. NO: ROUGH PLUMBING GAS PIPING .GAS VENT HOT WATER HEATER PLUMBING FIXTURES LAWN SPRINKLERS GAS TEST UTILITY COMPANY NOTIF D CWV GRAY WATER SYSTEM REPORT ID: DPR263 ROUTE TO: BS0508 COUNTY OF LOS ANGELES TEMPLE CITY # 0508 11a0MB'Ya NfB G PERMIlaTi DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 9598 99Q4200 73 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID UI'6 q KESS: TR• 13613 LT: 88 10793 BNA��,EK-NEE„A SISI FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP—EA-917803592 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: MCCULLOCH 8573-007-016 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 2.00 FIX 32.40 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 45 WATER CLOSET/URINAL 1.00 FIX 16.20 04/20/99 UT 04/20/00 TOTAL FEES 92.55 OWNER: TEL. NO: FINAL DATE FINAL BY: CODE: WINSTANLEY ERIK C;CATERINA RIZZI 10793 BLACKLEY ST TEMP 917803502 DESCRIPTION OF WORK iPL,U'MB'I46G oR'NEW-'U HROOM APPLICANT: TEL. NO: SAME AS OWNER SPECIAL CONDITIONS: CONTRACTOR: . TEL. NO: �� C�� APPROVALS DATE INSPECTOR SIGNATURE SAME AS OWNER - LIC. NO � UNDER SLAB WORK r WATER SERVICE PLASTIC Y/N METAL Y/N ARCHITECT OR ENGINEER: TEL. NO: r rl --' ROUGH PLUMBING LIC. NO•' ---- - GAS PIPING GAS VENT HOT WATER HEATER �_ �� '.�� J \_� �Ju tet✓ � PLUMBING FIXTURES LAWN SPRINKLERS �• �� Lj �I.T � GAS TEST UTILITY COMPANY NOTIFIED CWV GRAY WATER SYSTEM a� REPORT ID: DPR263 ROUTE TO: BS0508