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HomeMy Public PortalAbout9327 BLACKLEY ST_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I herdby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 insure,�ora certificate of Workers' Compensation Insurance, 76A667A br a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No73 �! Compony ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING E_11c"ertified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY Dat Applicant t WATER CLOSET U ©O NEAREST `J CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. A / COMPENSATION INSURANCE OWNS A MZ4lkA- (This section need not be completed if the work involved by SHOWER the permit is for one hundred dollars $100 or less. ayti MAIL p ( ) ) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. so as to become subject to the Workers'Compensation Laws. / DISHWASHER CONTRALTOno Date Applicant CLOTHES WASHER no ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL. NO with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER I 660 LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCE S D 6Y I hereby affirm-that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS KN (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my lic nse is in full force and effect. 5 PER SYSTEM FINAL �� V LIDATION 0. License Number Lic. ClassDATE i Q FINA Contractor Date BY W I am exempt under Sec. � B.&P.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Poo Signature TOTAL FEE Plan check applicant SINGLE FAMILY 5 HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License taiCCT a Address °Q Law for the following reason (Section 7031.5, Business and ,,�r�yy-7 r� Professions Code): City Tel. No. .`►,7V( 94.5 i ❑ I, as owner of the property, will do the work and the 1 ITEMS structure is not intended or offered for sale (Section t 7044, Business and Professions Code). lop, TOTAL 94.50 CONSTRUCTION LENDING AGENCY CHECK 94.50 1 hereby nffirm that there is a construction lending agency for the performance of the work for which this permit is issued CHANGE .00 (Sec. 3097, Civ. C.). lender's Name00 —'�,V'•Jl 7 I ')7 Wp Lender's Address 58-96 1 AN 4-044 1 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 obove_mPntioned pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si nature of Permittee Date" C�iiljTY OF LOS ANGELES TEMPLE PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TIMA' '50ul 0410250002 BUILDING "N`) SAFETY LAND DEVELOPMENT TE."'PLE ": ;`Y 01" 91780 PHONE: 6_'5-0488 EXT: ILEGAL ID: FEES PAID BUILDINC ADDRESS: ;rR: 11492 LT: 1 . oL: B 9327 BLACKLEY ST LE DESCRIPTION: QUANTITY: UOM: A M01 INT TEMP CA ASSESSOR INFORMATION NUMBER: NEAREST .1"ISS STREET: 8590-002-014 101 PERMIT ISSUANCE rEE 27.75 THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY, C 145 WATER CLOSET/URINAL 1.00 FIX 16.20 ,TENANT: j TOTAL FEES 43.95 ISSUED ON: PROCEZ§§E:r) PT- PLAN BY: EXPIRES ON: 10/25/04 JK 0 4 '23V 015 �GWNER: TEL. NO: FINAL DATE 1-_fNA C D E- 11,;.AZAICA, ELLEN (626) 285-664-9- /,-?— 2z 19327 BLACKLEY ST A� ' (-( /_1 TEMP 917803139 DESCRIPTION 0;- wURK Q-->— WATER HEATER CHANGE OUT IAPPLICANT: TEL. NO: DEPENDABLE ELECTRIC (818) 898--(401- DEPENDABLE 5TH ST. UNIT G SPECIAL CONDI_i'UNG: ISAN FERNANDO, 91340 ICONTRACTOR: 1E'L. " APPROVALS DATE DEPENDABLE ELECTRP_- (813) 8z,-3-7401- I 511 5TH STREET L-'C* NO UNDER SLAB WORK LlN I TG 3111--­ --- 1.! !SAN FERNANDO CA 91340 j WATER SERVICE ,PLASTIC Yilh! 'ARCHITECT OR ENGINEER: TEL. NO: ROUCH j GAS PIPING HOT WATER HEATER C( Gr 15 N_GF F,��- R E S_­ LAWN SPRINKLE,"T UTILITY COMPA­ '�OT17TED Cwv GRAY WATER SYSTEM ADDITIONAL DATA ON FILE REPORT ID: DPR263 ROUTE TO: BS0508