HomeMy Public PortalAbout9927 BROADWAY_Plumbing__ ..y WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I erebyr;pff irm that I have a certificate of consent to self 20-0026 DPW 6/07
insure, or a certificate of Workers" Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, Lab, C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished.
❑ FOR APPLICANT 70 FILL IN(PRINT OR TYPE) BUILDING C, 2
Certified copy is filed with the county building inspec- ADDRESS J �
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY TOM J)Lj CA-(-I -7 1 C{�
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. ( - 73 LV I
COMPENSATION INSURANCE SHOWER OWNER
.(This section need not be completed If the work Involved by MAIL
the permit is for one hundred dollars ($100)or lass.) LAvgTORV ADDRESS Z 22/c�l�ltil i
I certify that in the performance of the work for which this
permit is issued, I shall not em..p II y y pec m any manner SINK CITY'—[
so as to become subject to the Wor Com /,n�lotion Laws. DISHWASHER
//////////,,//nn�����/// �f/'/ CONTRACTOR ,
Date?.rApplicant !/(/(/`� CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, aftW making this Certificate of - ✓ v0) G (��
Exemption, you should become subject to the Workers SWIMMING POOL RECEPTOR /' 1 JJ l 0
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY r7"-S/J.D-'emA-�/h�� TEL. fes.
with comply with such provisions or this permit shall be STATE47 q I LIC.
deemed revoked. WATER HEATER / gitl(,zUV� / LICENSE NO. 5_5?_ C ( CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM _ !T
FINAL VALIDATIONDATE
License Number 5.SZQ � Lic. Class 22'�PL
M.4>� I Cl✓Allv.� BY AL
Contractor ?l On/'✓nom✓ (.Ut`T�/IDate
❑ I am exempt under Sec. U
W
B.BP.C. for this reason 0-'
Plan check fee Z
Date: PLUMBING PERMIT ISSUING FEE$ Poo�
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
EY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Licensegddress D'Z'�
Low for the following reason (Section 7031 5, Business and
Professions Code): City Tel. No. i�{{
❑ I, as owner of the property, will do the work and the 3"'
:1f 1.'
structure is not intended or offered for sale (Section
7044, Business and Professions Code). C1 u( ':6 s 50CONSTRUCTION LENDING AGENCY t. ._ s.
i hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
Hfdh3o�t i11
(Sec 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the0111. HIM, ! Ar
above ation is correct. I agree to comply with all County
qjJ4rT'a`nc0 and State laws gu lating Plumbing, and hereby
authoriy representatives of this ounty to enter upon the
abov¢c entionedp p for
__tion purposes.
7-- / SEE REVERSE FOR EXPLANATORY LANGUAGE
,$Ygnoture of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 iPLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS C--PL 0508 9703240030
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING-ADDRESS:
TR: 13805 LT: 8 �9927_BROADWAY— I
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802635
ASSESSOR-INFORMATION NUMBER: NEAREST CROSS STREET:
8588-015-008 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY
51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.35
TENANT: TOTAL FEES 44.10 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
03/24/97 TC 03/24/98
OWNER: TEL. NO: - FINAL DATE FINAL BY: CODE:
SWATER JUDITH E;JACK J
9927 BROADWAY I
TEMP 917802635 €CR PTION OF WORK
GAS LINE FOR NEW HEATING AND A/ SYSTEM
APPLICANT: TEL. NO:
HUNTINGTON AIR CONDITIONING (818) 285-5049-
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
HUNTINGTON AIR CONDITIONING, INC. (818) 285-5049- _
450 AGOSTINO RD LIC. NO UNDER SLA13 WORK
SAN GABRIEL, CA 91776 644769 C20
WATER SERVICE '
-'��
ARCHITECT OR ENGINEER: TEL. 0: -
PLASTIC Y/N METAL Y/N
ROUGH PLUMBING _ ..
LIC. NO:
- GAS PIPING
GAS VENT
HOT WATER HEATER
aC0�61F9 s
LAWN SPSP IZER-9-
S TEST
UTILITY COMPANY NOTIFrFD .
CWV
7�� GRAY WATER SYSTEM
REPORT ID: DPR263 ROUTE TO: BS0508
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 CPLUMBIWE PERMI
• DEPARTMENT OF PUBLIC.WORKS 9701 LAS TUNAS PL 0508-9997280013
BUILDING AND SAFETY / LAND DEVELOPMENT . TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT: - -
LEGAL I FEES PAID ULL G_91�DRESS:
TR: 13805 LT: 8 927 BROEW-a
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP T7802635
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
8588-015-008 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY
07 BATHTUBS/SHOWERS 1.00 FIX 16.20
TENANT: 11 CLOTHESWASHER(S) 1.00 FIX 16.20 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
25 LAVATORIES/SINKS _ 1.00 FIX 16.20, 07/28/99 UT 01/24/00
45 WATER CLOSET/URINAL 1.00 FIX 16.20
OWNER: TEL. NO: 47 WATER HEATER(S) 1.00 WTH 16.20 . FINAL DATE FINAL B `1 / CODE:
SWATEZ JUDITH E;JACK J (626) 287-1236- TOTAL FEES 108.75
9927 BROADWAY
TEMP 917802635 �� �•,,, p SCRIPTION Of WORK
e_eG, PLUM8TNG-FOR�DD1.Y.ION_AND_RELOCATE-WATER-NEATER
Off- y/3�19� —�
APPLICANT: TEL. NO:
MICHAEL G ROELLE PLUMBING (626) 960-0344-
5057 LANTE ST. - _ SPECIAL CONDITIONS:
BALDWIN-PARK, CA _
CicLES�Co
CONTRACTOR: TEL. NO: OS APPROVALS DATE INSPECT R SIGNATURE
MICHAEL G ROELLE PLUMBING AND - (626) 960-0344-
FIRE SPRINKLER CONT. INC. LIC. NO UNDER SLAB WORK
5057 LANTE ST. 743562 * �
BALDWIN PARK, CA 91706 - / WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT O GINEER: TEL. N0: / n
ROUGH PLUMBING
LIC. N0: I - 1111111 -
L GAS PIPING
GAS VENT
U S L�C �Al G FKS HOT WATER HEATER
PL GING FIXTURES
LAWN SPRINKLERS -
r r.,
GAS TES
UTILITY COMPANY NOTIFIED
n_
t� cuv .
t
b�7c service m' o
GRAY WATER SYSTEM
2- an
* ADDITIONAL DATA ON FILE
REPORT ID: DPR263 ROUTE TO: BS0508