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76A667-CE817 3-59
APPLICA'T'ION FOR PLUMBING PERMI`d'
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS /
JOHN A. LAMBIE, County Engineer { 9 942; B ��®
CASSATT D. GRIFFIN, Supt of Building LOCALITY Ten 1 e City -
FOR APPLICANT TO FILL IN NEAREST
CROSS ST. divi "
NUMBER FIXTURE OR ITEM I
OWNER John B. Kentis
WATER CLOSET MAIL
BATH TUB ADDRESS
943 Bogue
CITY Temple Ci
SHOWER L. NO, AT 600232.
LAVATORY CONTRACTOR I
SINK ADDRESS Q,`Z
DISHWASHER CITY TEL. NO. 0
CONTRACTOR'S STATE
LAUNDRY TUB �� REGISTRATION NO. ' g COUNTY ❑
CLOTHES WASHER- DISTRICTNO. GED—UB ZONE P OC$SSEDBY
WATER HEATER
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL
INSPECTION RECORD
O1.00 PER R FIXTURE $ I /(/
APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT $ 2100 UNDER SLAB WORK
TOTAL FEE — ROUGH PLUMBING
GAS PIPING
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. HOT WATER HEATER
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THAT I AM TH LE L NE THE ABOVE
DESCRIBED RESIDENTI P Y UTILITY CO.NOTIFIED
SIGNATURE e t
OF PERMITTE FINAL
OF =VAJ�IDATION ROBERT A. WOOD,
. "311 SUPERVISING MECHANICAL ENG'R
t
7. O" FEB 2-9 5 A 3.0'0
WORKER'S COMPENSATION DECLARATION 6DPW 9/89 APPLICATION FOR PLUMBING PERMIT
- 76A66 ,
I hereby affirm that I have a c4ertificate of consent to self insure, 76A667A r � \
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 I -
Poli
Certified copy is hereby furnished 9
EJ Certified
APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with'the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM p FEE LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST
BATH TUB
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) OWNER
I certify that in the performance of the work for which this permit LAVATORY
is issued, I shall not employ any person in any manner so as to SINK MAIL
become st to th Workers'Compensation Laws. ADDRESS
u c
DISWASHER CITY
b CLOTHES WASHER CONTRACTOR
N ICE'TO PPLICANT: If, after making this-Certificate of G
Exemption,you should become subject to the Workers"Compen sation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with-such ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.t,L 1't,- >_
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER TA E "''tom vv /LIC9 0
(commencing with Section 7000) of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NOej 4e ! � CLASS O
Professions Code,and my license is in full force and effect. �v
!
DISTRICT NO PRICESSED
OUTLETS OVER _� BY Q
5 PER SYSTEM �—D Q
-
License Numbe ,�- _ ir• Class 249 _ V
FINAL
�4pDATE z Z Gj VAC113ATION rj?tl
at FINAL F6 I ITEM. � � z
❑ I am�..empt �erSec BY. TOTAL 40 - 65
B.&P.C.for this reason
Date; Plan check fee , CHECK
Signature PLUMBING PERMIT ISSUING FEE$ CHANGE
e ;)
ElTOTAL FEE 17 a,
SINGLE FAMILY Plan check applicant l_iUI_ylA Jr r`{ f .-
i r 1J:
HOME OWNER-BUILDER DECLARATION , Name
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): '
EJ 1,
- 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)
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
representativ of this County to enter upon the ab a-men'oned
proper y for do urpos t- SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1106010016
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS.
ITR: 16557 LT: 5 I 9943 BOGUE ST I
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802632
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: BROADWAY
18588-014-022 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl
1 107 BATHTUBS/SHOWERS 1.00 FIX 16.30 I
(TENANT: I11 CLOTHESWASHER(S) 1.00 FIX 16.30 (ISSUED ON: PROCESSED BY: PLAN BY: I
I 113 DISHWASHER(S) 1.00 FIX 16.30 106/01/11 SR 1
I 121 HOSE BIBB(S) 2.00 FIX 32.50 1 I
1OWNER: TEL. NO 125 LAVATORIES/SINKS 3.00 FIX 48.80 IFINAL DATE FINAL BY: CODE: I
IVEENSTRA BARBARA J (626) 286-5330- 145 WATER CLOSET/URINAL 1.00 FIX 16.30
19943 BOGUE ST 147 WATER HEATER(S) 1.00 WTH 16.30
ITEMP 917802632 151 LOW PRS GAS 5 OUTLET 1.00 SYS 16 30 SCR`fPTION OF WORK �� I
I I TOTAL FEES 206.90 IPLUMBING FOR NEW BATHROOM AND REMODEL EXISTING KITCHEN, I
I I IBATHROOM AND RELOCATE WATER HEATER 1
(APPLICANT: TEL. NO:
IFIEL, JIM (626) 222-8803- 1 I I
1 I ISPECIAL CONDITIONS:
I
I I I I
CONTRACTOR: TEL. NO: I 1APPROVALS DATE INSPECTOR SIGNATURE I
IFIEL, JIM (626) 222-8803- 1
LIC. NO I (UNDER SLAB WORK
NONE I
I I
1 I IWATER SERVICE 1 I 1
I 1 IPLASTIC Y/N METAL Y/N I I 1
1ARCHITECT OR ENGINEER: TEL. NO I I I
IMUTKA, JASON (951) 235-0276- I IROUGH PLUMBING
1 LIC. NO: 1 1 1
NONE (GAS PIPING I 1
1 I IGAS VENT
I I I
HOT WATER HEATER I
IPLUMBING FIXTURES I I
ILAWN SPRINKLERS
I I I
1 I IGAS TEST I I I
I I I
I 1UTILITY COMPANY NOTIFIED(
I I ICWV I
IGRAY WATER SYSTEM 1
I I I I I I
I I I I I I
1 I I I I I
I I I I I I
• IREPORT ID DPR263 ROUTE TO: BS0508 1 I 1
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