HomeMy Public PortalAbout9965 BOGUE ST_Plumbing__ WORKERS'COMPENSATION DECLARATION 7ewee7w g P p 1 K A T I O N FOR PLUMBING P E R M I T
I he bj affirm that I have a' certificate of consent to self' ce sig (z-eo) /'1 r ` _ - •
ins e, or a certificate of Workers'Compensation Insurance,or
,a ertified copy thereof(Sec. 3800, Lab.C.) - r-- -
_,.COUNTY:OF.LOS.ANGELES-T BUI.LDING_AND;SAFETY-
)icy No.E�r!—�Company��ll1FV ;� —= - - -
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING-
ADDRESS u� '
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM FEE
departmen r., , WATER CLOSET LOCALITY `. Z
Q����..�
-Date Applicant_1� � — NEAREST -
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER -
LAVATORY
MAIL
(This section need not be completed if the work-involved t— ADDRESS_.C31A015 C-1- L a>_
by 'the permit is for one hundred dollars ($100) or less.) K O
SIN
CIT TEL. NO-. U
I,c'ertify that in'the performance of the work'for which this 1 DISHWASHER
P is•issued, I shall not employ'any person in any,manner ` CONTRACTOR t , O
so as to become subject to the Workers' Compensation Laws. , CLOTHES WASHER ADDRESS a 1� `� N U
Date Applicant SWIMMING POOL RECEPTOR d
NOTICE TO APPLICANT:.If, after making this Certificate of CITY TEL. NO. _ to
Exemption, you should become subject to- the Workers' LAWN SPRINKLER SYSTEM STATE LIC. Z
Compensation provisions of the Labor Code, you must forth- p ,,.�.��,�•. LICENSE NO. _fb CLASS
with comply with such provisions or this permit shall be WATER HEATER 9Z -+>AG �—
deemed revoked. ` GAS SYSTEM •OUTLETS DISTRICT NO. PRO ESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I:am licensed under-provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- :qF)NAL VALIDATION '
ness and Professions Code, and my license is in full force and DATE f ��
effect.
FINAL
License Number_.dl � Lic.Class BY
BY
-�, �G
Contractor Date
I am exempt from the licensing requirements as I am a Plan check fee �
licensed architect or a registered professional.engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity, (Section 7051, Bus- 1
LL
iness and Professions Code). TOTAL FEE
Lic,or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name A
I hereby affirm. that I am exempt from the Contractor's Address o o s o 0 5
License Law for the following reason Section 7031.5, Busi-
( City T.I.No. < < a
ness and Professions Code): 21'0?o 64,50
❑ I, as owner of the-property, am exclusively contracting _ '
with licensed contractors to construct the project �0 o 0 6 q,5 0
U
(Section 7044, Business and Professions Code). +. + '
03,`15'-84
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
abovinformat' is correct.I agree to comply with all County SEE REVERSE-FOR EXPLANATORY,LANGUAGE
ordi nces a d Sta laws regulating Plumbing, and hereby' .
auta ep s ntat ves this County to enter upon the
abo m pro t inspection purposes.
gnature of Pe mittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 P-LUMBING_PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUN*?'; -- PL 0508 9701280007
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL ID• FEES PAID CBUILD_ING_ADDRESS:
TR: 14984 LT: 6 \9965 ROGUE ST(
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: T&—PCA-917862632
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
8588-014-027 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY
13 DISHWASHER(S) 1.00 FIX 16.35
TENANT: TOTAL FEES 44.10 IISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
01/28/97 TC '01/28/98
OWNER: TEL. NO: FINAL DATE FINAL BY: CODE:
DUGGAN MELANIE D _��•-LI
9965 BOGUE ST
TEMP 917802632 DESCRIPTION OF WORK
CHANGEOUT OF DISHWASHER
APPLICANT: TEL. NO: �j �3�
MC DONALD ELECTRICAL SERVICE (909) 885-3827-
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO �" �•� L ` APPROVALS DATE INSPECTOR SIGNATURE
MC DONALD ELECTRICAL SERVICE (909) 885-3827- �ldf , 1 U
337 S. ARROWHEAD LIC. NO � � UNDER SLAB WORK U 'U
i 1 � \
SAN BERNARDINO, CA 92408 49139 B -- -— -
r -- - --- - - -- -- - - �'WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: TEL. N0: _.U �
---�-- --_ _ —� = ROUGH PLUMBING
LIC. N0: GAS PIPING
( J4 tl..J '—'' �!
� , � , GAS.VENT
HOT WATER HEATER
PLUMBING FIXTURES
LAWN SPRINKLERS
c/ GAS TEST
UTILITY COMPANY NOTIFIED
CWV
GRAY•WATER SYSTEM
r
REPORT ID: DPR263 ROUTE TO: BS0508