HomeMy Public PortalAbout9936 BOGUE ST_Plumbing__ =^ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
1 liereby,, affirm 76A66
that I have a cVrtificate of consent to self in- 6 DPW a/87
6A667A'
yore,ora certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
certified copy thereof (Sec. 3800, Lab. C.)
Policy No9-1-Z CompanyCOUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
❑ Ce ified 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 @ FEE
WATER CLOSET(TOILET) LOCALITY � ) G t
Date�V �✓ � Applicant /Vr-1 Qt L6hZJ NEARESTLli
/) . PJ
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
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COMPENSATION INSURANCESHOWER OWNER L� / p
(,�JI U-0
/ jYf /®Y
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100) or less.) LAVATORY 7,K:249 ADDRESS �+
I-certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so SINK CIT i TEL. NO. RC2
as to become subject to the Workers'Compensation Laws. / DISHWASHER A v
L CONTRACTOR Ao �
Date Applicant CLOTHES WASHER �!
ADDRESS �r
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR r�
emption,you should become subject to the Workers'Compen- CITY r7 T . NO. Z'j
cation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE r' UC.
ed. WATER HEATER LICENSE NO. 7' CLASS
LICENSED CONTRACTORS DECLARATION / DIST NO., PRB
1 hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS (/J/
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER `
fed Professions Code, and my license ✓
is in full force and ef- 5 PER SYSTEM FINAL Z VALI ATION
I DATE
License Number / Lic. Class _
FI V
._ g
Contractor Date O
ElI am exempt under Sec.
B.&P.C. for this reason PIcin check fee z 8 1 2 2 A g
Date: PLUMBING PERMIT ISSUING FEE$ # o o'0 0 0 5
Signature
SINGLE FAMILY TOTAL FEE I -o`0 6 G,5.0
HOME OWNER-BUILDER DECLARATION Plan check applicant
0 - 64, 506
064,506
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5,'Business and I 1 5-8 7
Professions Code): Address al
I, 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
(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
a b a-mentionedlpToperty for inspection purposes.
•� � � � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature "f ittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS PL 0508 9704170005
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 "EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 16557 LT: 7 9936 BOGUE ST
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802631
SSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
8588-015-020 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY
47 WATER HEATER(S) 1.00 WTH 16.35
TENANT: TOTAL FEES 44.10 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
04/17/97 TC 04/17/98
OWNER: TEL. NO: FINAL DATE FINAL BY: CODE:
TRUJILLO EUGENE;MARCENE TRS (818) 287-0382-
9936 BOGUE ST -
TEMP 917802631 DESCRIPT ON OF W R
CHANGE UT OF WATER HEATER
APPLICANT: TEL. N0:
RBI, INC. (909) 594-3686-
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
RBI, INC. (909) 594-3686-
3940 VALLEY BLVD. UNIT D LIC. NO UNDER SLAB WORK
WALNUT, CA. 91789 683107 C36
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: TEL. NO:
- ROUGH PLUMBING
LIC. NO:
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: BS0508