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Home My Public Portal About9237 BLACKLEY ST_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby, affirm that I have a certificate of consent to self in 76A6667A PW 4/9D sure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof (Sec 3800, Lab C ) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No Company 1 Certified copy is hereby furnished FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESS OBJ department NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant / WATER CLOSET(TOILET) ✓ NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST COMPENSATION INSURANCE SHOWER NER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars($100)or less ) / LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK CITY TEL NO mit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws DISHWASHER �) t' ``7T^ CONTRACTOR Date —5` 5 Appl scant �amV n fig- CLOTHES WASHER NOTICE TO APPLICANT If, after making this Certificate of Ex- ADDRESS em ,you tionshould become subject to the Workers'Com en- SWIMMING POOL RECEPTOR P Y I P CITY TEL NO sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or This permit shall be deemed revok- STATE LIC A ed WATER HEATER LICENSE NO CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS Ll� 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM� FINAL t .—VALIDATION fect HOSE BIB DATE License Number Lic Class FINAL I'�1 �_ ' s e V Contractor Date BY 333 j ��e�l� 0 I am exempt under Sec 1 17 E11c, 0 B 8P C for this reasona Plan check fee _ 10. TOTAL �,�',� �, 00 N Date PLUMBING PERMIT ISSUING FEE$ j 75, Signature +��RC',E TOTAL FEE ��ji Q D SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name 0000-000-1 f �j`, Law for the following reason (Section 7031 5, Business and Professions Code) Address )� � t fy 40l El 1, as owner of the property, will do the work and the City Tel No structure is 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 o- (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 y ordinances and State jaws regulating Plumbing, and hereby authorize represetatives of this County to enter upon the above-rn nti er y.for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE duy(aefu'r-elot Permittee Date WORKER'S COMPENSATION DECLARATION 20 0026 DPW 9/89 76A667A APPLICATION FOR PLUMBING PERMIT LJ 76A667 I hereby affirm that I have a ceridicate of consent to self insure or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV Policy No Company ❑ Certified copy is hereby furnished BUILDING F-1ADDRESSAPPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Certified copy is filed with the county building inspection department NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSSST COMPENSATION INSURANCE (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less) OWNER / I certify that in the performance of the work for which this permit LAVATORY is issued, I shall not employ any person in any manner so as to SINK MAIL ADDRESS become subject to the Workers'Compensation Laws _ DISWASHER CITY TEL NO Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code,,you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL�O I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER _ (commencingwith Section 7000 of Division 3'of the Business and STATE LIC _ _ O ) / GAS SYSTEM � OUTLETS � l LICENSE NO CLASS . s- Professions Code,and my license is in full force and effect t - OUTLETS OVER DISTRICT NO PROCESSED B _ 5 PER SYSTEM )Ers Q License Number Lic Class i,_ +r` ti P FINALIth DATE VALIDATION Q. Contractor Date ' y / ❑ FINAL 4�, -R'i1IE 4 •-Z I am exempt under Sec BY J '+�4'" B&P C for this reason Plan check fee Date - PLUMBING PERMIT ISSUING FEE$ � Signature -'- ❑ TOTAL FEE I� Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name l I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Business and Professions Address 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 7044, Business , and Professions Code) / / J CONSTRUCTION LENDING AGENCY 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 law AlatiPlumbing, and hereby authorize representativ of to enter upon the above-mentioned' property for pecs SEE REVERSE FOR EXPLANATORY LANGUAGE r\S na re f e Ittee Date • COUNTY OF LOS ANGELES TEMPLE CITY # 0508 UMBI __ hyTr DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS @5@ 908259004 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE (626) 285-0488 EXT: -LEGALID PAI G R S• TR: 11492 LT: 14 BL: A LA@KLEyS� FEE DESCRIPTION: QUANTITY- UOM: AMOUNT: �IT780ltt ASSESSOR INFORMATION NEAREST CROSS STREET: ENCINITA 8590-001-017 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: A LOCALITY: TEMPLE CITY 07 BATHTUBS/SHOWERS 1 00 FIX 16.20 TENANT: 25 LAVATORIES/SINKS 1.00 FIX 16.20 ISSUED ON PROCESSED B A BY: EXPIRES ON 45 WATER CLOSET/URINAL 1.00 FIX 16.20 08/25/99 UT 02/21/00 TOTAL FEES 76 35 OWNER: TEL. NO: FINAL DATE FINAL DE: PASTOR DENIS;VILLALOBOS MARIA CRIST (626) 285-4159- 9237 BLACKLEY ST TEMP 917803137 DETCURTION OF WORK PLUMBING FOR RELOCATING BATHROO APPLICANT: TEL. NO- SAME AS OWNER SPECIAL CONDITIONS: CONTRACTOR: TEL. NO: �.'®�/� AP R'ROOVALS DA INSPECTOR SIGNATURE �®� SAME AS OWNER LIC NO UNDER SLAB WORK q/� WATER SERVICE < i PLASTIC YIN METAL YIN ARTFT-9CFOR ENGINEER: TEL. A 9ROUGH PLUMBING ,q LIC. N0: ( 111111 L Y�S�iHt L , r S VE G UU C V V OO IF-I WATER HEATER PLUMBING O O &�PR TKL FIXTURES ❑ r*' AS TEST ❑ ® ®yUTILITY COMPANY NOTIFIE5 46''C CwV `�ePVIC�� OQ GRAY WATER SYSTER REPORT ID: DPR263 ROUTE TO: BS0508