HomeMy Public PortalAbout5826 BURTON AVE_Plumbing__ {.. t,VORKERS' COMPENSATION DECLARATION APPLICATION FOR �������� PERMIT l'I
I hereby dff'izm 0
that I hove a certificate of consent to self 20026 DPW 6/87
irKbre, or a certificate of Workers' Compensation Insurance, 76A667A
or y,ceRified'copy thereof (Sec.3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy t o. Company
fL�J' Certified copy is hereby furnished.
' FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
❑ Certified copy is filed with th c my bui ng in ec- - ADDRESS
tiond ' a ment. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
IMLAppliqo / WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WOR S' BATH TUB CROSS ST.
COMPENSATION INSURANCE. ' SHOWER OWNERAga N
(This section need not be completed If the work Involved by MAIL /
the permit Is for one hundred dollars ($100)or less.) LAVATORY ✓ ADDRESS �O
I certify that in the performance of the work for which this ✓
permit is issued, I shall not employ any person in any manner SINK -_5Z,
CITY I TEL. NO.�g _
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR 'SUL
Dote Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTORhVI
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- CITY TEL NO,
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT N�, PROCESSED BY
I hereby off irMLthat I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �' g
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and m Ilcense is in full force and effect. 5 PER SYSTEM
y FINAL / VALIDATION 0.1
License Number Lic. Class DATE f I c� L U.
U.
FINAL 0
Contractor _Date BY - 0
❑ I am exempt under Sec. (~,)
GV W
B.BP.C. for this reason D.'
Plan check fee D Z
Date:
' - PLUMBING PERMIT ISSUING FEE$ �3 "' S
Signature
TOTAL FEE
Plan check applicant 3307 838.0
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name 1 ITEMS
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address TOTAL LS m 00
Professions Code): City Tel. No. CHECK
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section D CHANCE ,Citi
7044, Business and Professions.Cade).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 1313130-13001 10/ 3/90
the performance of the work for which this permit is issued '
(Sec. 3097, Civ. C.). 3104 .1 AM 8e4t,
Lender's Name
Lender's Address
I certify that I'hove read this application and state that the D
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
Signature of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0209180024
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDINGADDRESS:
TR: 3623 LT: 118 BL: .001 5826 BURTON AV N
FEE DESCRIPTION: QUANTITY: LOM: AMOUNT: SGAB CA 917753075
ASSESSOR INFORMATION NUMBE : NEAREST CROSS STREET: HERMOSA
5387-006-027 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: G3 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: E .
25 LAVATORIES/SINKS 1.00 FIX 16.20 09/18/02 JK 03/17/03
45 WATER CLOSET/URINAL 1.00 FIX 16.20
OWNER: TEL. NO: TOTAL FEES 92.55 F INAL,DATE.' FINAL BY: CODE:
BASILE STEVEN L;LINDA A (626) 286-5096- ��--
5826 BURTON AV p�°"J�`�
SGAB 917753075 CR OF WORK
PLUMBING FOR CONVERSION
APPLICANT: EL. O:
SAME AS OWNER -
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER
LIC. NO UNDER SLAB WORK
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: TEL. 0:
ROUGH PLUMBING L: -
LIC. NO:
GAS P NG Tj
S VENT
H5TWATE_RHEAT ER
PFLUMBFNG FIXTURES
EXAN—SWINKLERS
GAS TES
UTILITY COMPANY NOTIFI
cWV
GAY WATER SYSTEM
REPORT ID: DPR263 ROUTE TO: SS0508