HomeMy Public PortalAbout9835 BROADWAY_Plumbing__ 20-0026
WORKER'S
haveCOMPENSATION of consent to 76AG67A PW 91
89 APPLICATION FOR PLUMBING PERMIT IJ
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy there (Sec.3800 Lab. C.)
Policy
Jn/ COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
P❑ No. ? ompany , vn� �/
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING L
/ �V A
u Certified copy is filed with the count boilding;inspectiADDRESS
on
_department. / NUMBER FIXTURE OR ITEM [rq 'FEE LOCALITY •/C� /� ���t
Date`' -� l Applicant WATER CLOSET _
NEAfl EST /
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
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.) LAVATORY OWNER
I certify that in the performance of the work for which this permit j ��'"`•••"'nn fr �^1
iMAIL
s issued, I shall not employ any person in any manner so as to SINK ADDRESS
become subject to the Workers' Compensation Laws. )J _
DISWASHER CITY �� /�"�j TEL.NO.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CLOTHES WASHER CONTRACTOR
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS ? f,'1/
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY /f TEL.N0. , - 17
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER �U e! , '��� a a•
(commencing with Section 7000) of Division 3 of the Business and STATE i LIC.
Professions Code, and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. ,� CLASS
OUTLETS OVER DISTRICT NO, PROCESSED BY Q
5 PER SYSTEM :7 Q
License Nt mbe/^�Z2Lic.Class 15(5 �U ~
+�f ,y � ram FINAL /1 3VANDATION a
Contracto7'/pP�l'�?//� �.� AfPa(e DATE _
❑ E. Z
I am exempt under Sec.
J:, FINAL HL -7.tr z
B.&P.C.for this reason 3307 40.:;`
Date: Plan check fee 1 ITEMS
Signature
PLUMBING PERMIT ISSUING FEES TOTAL 0 65
F1TOTAL FEE ® �- 4
yl {c
SINGLE FAMILY Plan check applicant CHANGE
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): uvV �I.j]1 1 .j.`7 1? ?':
❑ City Tel. No. •I A4 -
I,as owner of the property,will do the work and the structure v44]. hill: ;)
is not Intended or offered for sale (Section 7044, Business
and Professions Cade). - D
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 D
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
pry' tor'ns ection poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9901 LAS TUNAS PL 0508 1307310014
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 DUPLICATE
PHONE: (626) 285-0488 EXT:
ILEGAL ED I FEES PAID BUILDING ADDRESS:
ITR: 13805 LT: 16 1 9835 BROADWAY
IEEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA 917802634
(ASSESSOR INFORMATION NUMBER I INEAREST CROSS STREET: GOLDEN WEST
18588-015-016 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY CAI
1 113 DISHWASHER(S) 1.00 FIX 16.20
ITENANT: 125 LAVATORIES/SINKS 1.00 FIX 16.20 ISSUED ON: PROCESSED BY: PLAN BY:
147 WATER HEATERS) 1.00 WTH 16.20 107/31/13 SR
151 LOW PER GAS 5 OUTLET 1.00 SYS 16.20 1 1
OWNER: TEL. NO: I TOTAL FEES 92.60 IFINAL AT,E FI AL^BY: CODE:
KUMAR, DEVESH (626) 445-7666- 1 1 '"7//ny
19835 BROADWAY I 1 90 � 3 ,
ITEMP 917802639 D2SCRIPTION OF WORK
IDISHWASHER, SINK, GAS LINE AND INSTALL TANKLESS WATER HEATERI
APPLICANT: TEL. NO:
SAME AS OWNER -
SPECIAL CONDITIONS:
I
CONTRACTOR: TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE
(SAME AS OWNER - 1
LIC. NO 1UNDER SLAB WORK
(WATER SERVICE
_ PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: TEL. NO:
IROUGH PLUMBING
I I I
LIC. NO:
IGAS PIPING
(GAS VENT
IHOT WATER HEATER
I I I
(PLUMBING FIXTURES
LAWN SPRINKLERS
IGAS TEST I I I
1 1
IUTILITY COMPANY NOTIFIEDI I I
CWV
(GRAY WATER SYSTEM
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11 I I_ I I II
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IREPORT ID: DPR263 ROUTE TO: BS0508
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