HomeMy Public PortalAbout9443 BROADWAY_Plumbing__ CE BSJ IFEV.b/>BI (//Ev/]I/ `N�✓/ / `�-'✓F��•. 1 LIL111
APPLICATON�,FOR PLUMBING PERMIT
COUNTT � 0ApNGELE R' FR:M &IQSRUN W
FORAPPLICANT TO FILL IN IPRINT.OR TYPEI BUILDING .j EL
NUMBER FIXTURE OR ITEM ® FEE ADDRESS
WATER CLOSET LOCALITY
NEAREST
BATH TUB CROSS ST.
SHOWER OWNER
LAVATORY MAIL
ADDRESS
SINK CITY. TEL.NO n 1
DISHWASHER CONTR
CLOTHES WASHER ADDRE10920 E. GRAND'AVE.
SWIMMING RECEPTOR
LAWN SCITY TEMPLE CITY. CAUFes. -
LAWN SPRINKLER SYSTEM STATE LIC.
WATER HEATER LICENSE NO. � CLASS
GAS SYSTEM OUTLETS APPROVALS DATE INSPECTOR'S SIGNATURE
OUTLETS OVER UNDER SLAB WORK
S PER SYSTEM ROUGH PLUMBING
96N
GAS PIPING 0
Q
GAS VENT V
HOT WATER HEATER 0
PLUMBING FIXTURES G
GAS TEST 6
Plan Check fee UTILITY CO.NOTI EIED 6:
PLUMBING PERMIT ISSUING FEE$
n
TOTAL FEE FINAL
Pion check applicant
PI-M,4 CHECK VALIDATION
..� Ro0/Ua�c1
Nome
Address
NOv/T/ Ds7 ,3 20'�9�
City Tel.No. '
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE
THAT THE ABOVE ISCORRECTAND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
AND STATE LAWS REGULATING PLUMBING. PERMIT VALIDATION G 2 9 21 A
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS �/
REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE # O O O O O 5
LEGAL
OFOW.NER OF.AND THE ABOVE DESCRIBED RESIDENTIAL
PROPERTY
2 O O 1� U
O O
NATURE Uoo
'
P O O O
DISTRICT NO. ROCESS BY o226 —79
a Z�
INDUSTRIAL
WASTE APPROVAL
WORKERS'COMPENSATION DECLARATION APPLICATION FOR Ir ILn PLUMBING PERMIT
I}tereby, affirm that I have a certificate of consent to self in- �6A�a6 ADPW 4/90 LLN �7
Sure,or a certificate of Workers'Compensation Insurance,or a
certified copy thereof (Sec. 3800, Lab. C.) - -
.3502524 Company Republic Indemnity BOUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
PDlicy No
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT.OR TYPE) BUILDING
Certified copy is filed with the county building inspection - _ ADDRESS Q431 Rrni(`lw,)V
department. .y��.� LOCALITY
NUMBSR FIXTURE OR ITEM @ , FEE
Dille Applican
6/24/95 G �,v� Temple City
h///�// �`ti WATER CLOSET(TOILET) O NEAREST -
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB _ C7 CROSS ST.
COMPENSATION INSURANCESHOWER n - OWNER T.S. L . CONSTRUCTION
2
(This section need not be completed if the work Involved by MAIL -
the permit is for one hundred dollars ($100)or less.) LAVATORY �t} ADDRESS 1103 S . San Gabriel Bl .
I certify that in the performance of the work for which this per- SINK /3 T
mil is issued, l shall not employ any person in any manner so CIN San Gabriel TEL NO285-2925
as to become subject to the Workers'Compensation Laws. DISHWASHER
�s conlrRAaoF�rank Marrone & Sons In
Date Applicant CLOTHES WASHER J . ADDRESS 9860 Lower Azusa Rd.
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL NOL1, d
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEMS E l Monte 44-2 5 8
ly with such provisions or this permit shall be deemed revok- STATE I.C.
ed. / WATER HEATER - LICENSE NO. 397884 CLASS C/16 G 6
LICENSED CONTRACTORS DECLARATION s DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business _f OUTLETS OVER
and Professions Code, and my license is in full farce and ef- s�-� 5 PER SYSTEM - FINAL VALIDATION
fact. DATE
_ HOSE BIB �ji _
License Number 397882. Lic. Class C/1 tit/36 a
FINAL Q
Contractor Frank MarrOrlC"Dote 19 / 1 /RK BY
<<c Q
❑ I am exempt under Sec. V
B.&P.C. for this reason 1 i�-I'�` W
Plan check fee D • - o oe a
ILIAL ,�,--,�s" c �-Em
Date: PLUMBING PERMIT ISSUING FEE$ `,t Fry :G9 r_cZ
Signature
SINGLE FAMILY TOTAL FEE ff CHANGE
HOME OWNER-BUILDER DECLARATION _ Plan check applicant ,
I hereby affirm that I am exempt from the Contractor's License Name 3O'
Low for the following reason (Section 7031.5, Business and IjZl r4
Professions Code): Address 72:40 i A litl=
❑ 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). D -
CONSTRUCTION LENDING AGENCY r
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 D '
ordinances and State laws regulating Plumbing, and hereby
a thorize�pesentatweserl of this County to enter upon the
ov zeroperty for inspection purposes.
W,/ V O, �, :e SEE REVERSE FOR EXPLANATORY LANGUAGE -
Signature of Permittee�//7 Date