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Home My Public Portal About9951 BROADWAY_Plumbing__ WORKERS' SATI°N DECLARATION APPLICATION FOR PLUMBING PERMIT I h¢rebI have a y, affirm that have a certificate of consent to self in, 20-0026 DPW 4/W sure,or atertificafe of Workers Compensation Insurance,or a 76A667A certified copy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS [IILJIII Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) ILDI SNG S 7 Ti �V Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER WNER ` 1 (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK CITY TEL. NO. mit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws.. DISHWASHER CONTRACTOR Date. Applicant CLOTHES WASHER eq ADDRESS NOTICE TO APPLICANT.: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption, you should become subject to the Workers'Compen- CITY TEL. NO. sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS Iy with such provisions or this permit shall be deemed revok- STATE UC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. / PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS QD p 9(commencir ith Section 7000)of Division 3 of the Business OUTLETS OVER O and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL 1 VALIDATION fect. HOSE BIB DATE License Number Lic. Class 5 a FINAL0 Contractor Date BY ACCT.`r U cc I am exempt under Sec. n a�OJ 59.50 B.BP.C. for this reason , po"� O (/ 1 ITEMS yt Plan check fee (� r /Q u, Date: PLUMBING PERMIT ISSUING FEE$ a 30 TQTAL '9 a c0 Z Signature CHECK. 59.50 TOTAL FEE SINGLE FAMILY CHANGE .00 HOME OWNER-BUILDER DECLARATION Plan check applicant hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and 00000 0001 11/17/95 Professions Code): Address 3355 1 PM12:02 I, as owner of the property, will do the work and the City Tel. Na. structure is not intended or offered for sale(Section 7044, Business and Professions Code). ► 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 11110,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. t i SEE REVERSE FOR EXPLANATORY LANGUAGE \S 1 - 1 I (\SigIT nature of Permittee Date ' COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0306090004 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES P BUILDING S: TR: 13805 LT: 4 9951 BROADWAY FEE DESCRIPTION: QUANTITY: LOM: AMOUNT: TEMP CA 917802635 ASSESSOR INFORMATION NUMB . NEAREST CROSS STREET: BALDWIN 8588-015-004 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY 51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20 TENANT: TOTAL FEES 43.95 ISSUED ON: PROCESSED BY: PLAN Y: PIRES ON: 06/09/03 JK 12/06/03 OWNER: TEL. NO: FINA DA // FINAL BY: CODE: 9951 BROADWAY Y AND DONNA Y (626) 286-8228- 9951 BROADWAY TEMPLE CITY 91780 UtbLylviluN OF WORK GASLINE FOR HVAC APPLICANT: TEL. NO: SAME AS OWNER - SPECIAL CONDITIONS: CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATOR SAME AS OWNER - LIC. NO UNDER SLAB WORK WATER SERVICE PLASTIC Y/N METAL Y/N ARCHITECT OR ENGINEER: TEL. NO: ABLE DESIGN AND CONSTRUCTION CO. (909) 869-0732- ROUGH PLUMBING 20160 PASEO DEL PRADO #H LIC. NO: WALNUT, CA. 91789 668681 B GAS PIPING GAS VENT HOT WATER HEATER PLUMBING FIXTURES LAWN SPRINKLERS GAS TEST UTILITY COMPANY NO IED CWV GRAY WATER SYSTEM REPORT ID: DPR263 ROUTE TO: BS0508 COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0306050002 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING DD S : TR: 13805 LT: 4 9951 BROADWAY FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802635 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: BALDWIN 8588-015-004 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY 07 BATHTUBS/SHOWERS 1.00 FIX 16.20 TENANT: 25 LAVATORIES/SINKS 1.00 FIX 16.20 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 45 WATER CLOSET/URINAL 1.00 FIX 16.20 06/05/03 JK 12/02/03 TOTAL FEES 76.35 OWNER: TEL. NO: FINAL. ATE FINAL BY: CODE: LO;STEVEN Y AND DONNA Y (626) 286-8228- /[ 9951 BROADWAY ;2 '//" -- TEMPLE CITY 91780 DESCRIPTION OF WORK PLUMBING FOR ADDITION APPLICANT: L. NO: SAME AS OWNER - SPECIAL CONDITIONS: CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE SAME AS OWNER LIC. NO UNDER SLAB WORK (GIrJ UQ-K om 1 1 16-v3 WATER-----§E-RVI CE PLASTIC Y/N METAL Y/N ARCHITECT R ENGINEER: TEL. NO: ABLE DESIGN AND CONSTRUCTION CO. (909) 869-0732- ROUGH PLUMBING 20160 PASEO DEL PRADO #H LIC. N0: 0L.(0'c WALNUT, CA. 91789 668681 B G S ING GAS VENT HOT WATER HEATER 1 PLUMBI G %TURES / LAWN-SPRINKLERS S TEST UTILITY COMPANY NO FIED CWV GRAY WATER SYSTEM 7—/6 -o3 c Tu :4c� �f,+F G.u�0/7/FR////(.7//(/Er•J REPORT ID: DPR263 ROUTE TO: SS0508