HomeMy Public PortalAbout9008 - 9010 BROADWAY_Plumbing__ WORKERS'C hove'a P,AON DECLARATION APPLICATION FOR PLUMBING PERMIT
hereby, affirm that I hove'a certificate of consent to self in- 76A667A 4/87
sure,or d certlficote of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
certified copy thereof (Sec. 38QQ Lab. C.)
a - L74 Og` /�� a COUNTY OF LOS ANGELES DEPT. OF PUBLIC ORKS
Policy No. h/G -S Company ✓ / v f
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING c- _
F-] Certifiedcopy is filed with the county building inspection ADDRESS p
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Gi/ �Applicant IR /< WATER CLOSET(TOLET) '—
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
HATH TUB CROSS ST. JI"u. 11
COMPENSATION INSURANCESHOWER _ OWNER
(This section need not be completed If the work involved by MAIL
the permit Is for one hundred dollars ($100) or less.) / LAVATORY O 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 CITY A"-? ��//'�- TEL NO,
as to become subject to the Workers' Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER '
NOTICE —
TO APPLICANT: I /
after making this Certificate of Ex- j e �p✓✓O 7`
emption,you should become subject to the Workers'Com pen- SWIMMING POOL RECEPTOR ADDRESS CITY : TEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM �� z,/J
ly with such provisions or this permit shall be deemed revok- STATE LIC �.�
ed. WATER HEATER LICENSE NO. 5� �6 :�-> CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT O. ROLES ED B
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
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
fect. FINAL VALIDATION >
VC'3/L S' A
License Number Lic. Class �—Z b xr;4'a ,v `r�4� DATE O
G. c✓/G� y�.s� L /y•• s_•r-lcS FINAL V
ContractorY13bfe " BY
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I am exempt under Sec. _ W
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Plan check fee , w
Z
Date: PLUMBING PERMIT ISSUING FEE $
Signoture
TOTAL FEE j U
• SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant -
I hereby affirm that I am exempt from the Contractor's License Name - 33117 - 34.51)
Law for the following reason (Section 7031.5, Business and
Professions Code): ..Address 1 ITEt18
E] I, as owner of the property, will do the work and the City Tel. No. • TOTAL 34 - 50
structure is not intended ar offered for sale(Section 7044, 7, �_
Business and Professions Code). CHECK 34SU
.
CONSTRUCTION LENDING AGENCY ► CHANGE
I hereby affirm that there is a construction lending agency for '
the performance of the work for which this permit is issued
0000-00101 1 11/28/3-9
(Sec. 3097, Civ. C.).
Lender's Name /v�/P/2 1062 1 AN 9:20
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
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatua Permittee Date
,COUN(Y OF LOS ANGELES TEMPLE CITY # 0508 PLUMBI NSGPERM ITj
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS PL-%0508 9810130026
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (818) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING-ADDRESS: -
TR: 11218 LT: i BL: A 5450-ROSEMEAD-BL
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: SGAB CA 917762213
ASSESSOR88-003 IN ORMAT ON NU BER: NEAREST CROSS STREET: BROADWAY
5388-003-002 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H4 LOCALITY: TEMPLE CITY
17 FLOOR DRAIN(S) 1.00 FIX 16.20
TENANT: TOTAL FEES 43.95 ISSUED ON: PROCESSED BY: PL BY: EXPIRES ON:
JAY'S SHELL 10/13/98 UT 10/13/99
OWNER: TEL. NO: /?
FINAL DATE FINAL BY:
SITEMAN ROBERT H;BARBARA L - '
b a02R �
DE�PTI OF LF WOR _
REMOVE-AND-CAP-OFF-HAZARDOUS WASTE_.DRAIN WHICH IS NOT
BEING-USED ="
APPLICANT: T N0:
JOE RHODES MAINT SERVICE, INC. (714) 891-8777-
SPECIAL CONDITIONS:
Ph1GELES CO
CONTRACTOR: TEL. NO: S
Mry APPROVALS DATE INSPECTOR SIGNATURE
JOE RHODES MAINTENANCE (714) 891-8777- �.
14582 GOLDENWEST #C LIC. NO UNDER WORK
WESTMINISTER,CA 92683 445204BC10
WATER SERVICE
ARCHITECT OR ENGINEER: TEL. N0: PLASTI. Y/N METAL Y/N
ROUGFPLU B NG
LIC. NO: �' 7111117
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REPORT ID: DPR263 ROUTE TO: BS0508