HomeMy Public PortalAbout4853 CAMELLIA AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION - APPLICATION F® PLUMBING, PERMIT
I hereby affirm that I have o certificate of consent to self 20-0026 DPW 6/87
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. BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS r- 4
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY
Date Applicant WATER CLOSET NEAREST ,I
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. A
zj
COMPENSATION INSURANCE SHOWER OWNER.
(Th action need not be completed if the work Involved by MAIL
the Pe if is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify t t in the performance of the work for which this
permit is iss d, I shall not employ any person in any manner SINK CITY Ar,-�Cclt� GQ TEL. NO.
so as to beco subject to the Workers'Compensation Laws, DISHWASHER CONTRACTOR
Date plicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: 9. after making this Certificate of �l/tJGE.2i
Exemption, you should becpSWIMMING POOL RECEPTOR
me subject to the Workers" CITY TEL. NO.
Compensation provisions of theLabor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. �_ WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. n PROCESSED By
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER Cl G }}
and Professions Code,and my license is in fullfarce and effect. 5 PER SYSTEM FINAL VALIDATION pt
DATE '
License Number lis Class V;
FINAL
Contractor Date BY / 0
❑ I am exempt under Sec.
W'
B.BP.C. for this reason
Plan check fee to
Date: Z'
PLUMBING PERMIT ISSUING FEE$ -
Signature -
TOTAL FEE
Plan check applicant A, I.,
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and j .7 fp
C
Professions Cade): City Tel. No. ':1;1sL = .3
I, as owner of the property, will do the work and the C` " fes!
structure is not intended or offered for sale (Section ® MOCK K �..
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.) _ - �•)_li_'.i;4—I_ii'"f '
Lender's Name ,yU� t-- - _
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 4
ordinances and State laws regulating Plumbing, and hereby `
authorize representatives of this County to enter upon the
ove-mentioned property for inspection purposes. `
SEE REVERSE FOR EXPLANATORY LANGUAGE t
ignature of Permittee Dae
COUNTY OF LOS ANGELE`; TEhPLE CITY n 0508 PLUMBING PERMIT
DERARTMENT OF PUBLIC 9;01 I.AS TUNAS PL 0508 0410'120935
BUILDING ANO SAFETY / LAND TEM' .LE CITY CA 91780
r �r.E: (626) 285-0488 EXT:
LEGAL ID: FEES PRIG ADDRESS: i
TR: 14467 LT: 43 ? CAMP_LIA AV
_ __ FEE DESCRI P?ICYc - QUANTITY: i AMOUNT: "i-i% 0/7904241
ASSESSOR.INFCRMA1i0N NUMBER: --- +tl FST CROSS STREET: LOWER AZUSA
8589-015-020 01 PERMIT ISSUANCE FEE 27.75 Tiir�'.'�.AS PAG"e: 597 GRID: A5 LOCALITY: TEMPLE CITY, Li
_ 07 BATHTUBS/SHO'jERS 2.00 FIX 32.40
TENANT: 11 CLOT HES:JF.S HER(`.) 1.00 FIX 16.20 ISSUED .` . n^.CESSEG Y: PLAN B'!: E ?IR0— j
21 HOSE BIBBM 2.00 FIX 32.40 10/12/04• JK 04/10/0S 5
25 LAVATORIES'SINKS 2-00 FIX' 32.40
OWNER: ?F r0: 45 WATER CLOSET;L'RiNA! 1.O0 FIX 16.20 FINAL FINAL BY: CODE:
CHENG JIAN H;DENG MEI ZHEN (626) 695-0864- 47 WATER HEATER'S) 1.00 WTH 16.20
4853 CAMELLIA AV 56 GAS REGULATO° 2-CO REG 32.40
TEMP 917804241 TOTAL FEES 205 AS DESCRIPT;ON OF WORK -I
PLUMBING FOR THE GUEST HOUSE
APPL C—�— hO:
SAME AS OWNER. -
SPECIAL UONUt HUNS: .---�—'— --
I
CONTRACTOR: %L. NC APP ROVA.i"a DATE iNSPECTOP, SIGNAIURE
SANE AS OWNER - I
LIC. NO UNDER SLAB WORK ,
WATER SERVICE
PLASTIC YIN METAL Y/N
A 27 C4IT[LT GR °kGINEEF.: T`cL fi0:
- C!(;'ri P:_o:n:6if7i7 riy/ i�
IG—AST 1P
I
GAS '.'ENT
HOT ::IATE, IiLTii Eft
i �PLEU>�'•s?lG FIX1l1EE:-' -- -�— ��
_--_
I LRWN 9_Pkjy KLERS
I i
UTUTT!ITY COM?ANt NOTiFIE
i
CWV
GRAY RATER SPEY,
i
I I
I
REPORT ID: DP'263 ROUTE TO: 650508
COUtiTY OF LOS ANGELI TEMP;.ii Ci ;X51NG PERM 1'i
r,]RTMENT OF PUBLIC 9i`i'.;S 97C JJAS 0508 0111012GC1;.
6UILDIi:GANi. >AFETY / LAND DEVEL('MENI TEMPLE "
EMPLE c CA 91780
('u��; 285-0488 EXt
LEGAL ID:
TR: 14467 FEES PATO .
4853 CAMELLIA AV
FEE DESCRIPT I^ , 2UANTITY: UCS: .+tout"': EE;% 042 ?
ASSESSOR INFORM^i1 *, NLA!!, -1-J STREET: LOITER ,,^,ZIh'
8589-015-020 .OI PERMIT ISSUPA+ E FEE 27.75 Tnuiin_ P6:G:. 597 GRID: A5 _OCAL17: TEMPLE CITY, C
_ _ 07 BATHTUBS/SHOWERS 2.00 FIX 32.40 __
TENANT: —�-�� 21 HOSE BIBB(S;' 2.00 FIX 32.40 ISSiIEO ON: Pfi.-'-ESSEU BY: PLAN BY: .XPI;;ES ON:
25 LAVATORIES/,!' S 2.00 FIX 32.40 10/12/04
____ 45 WATER CLOSET/URir,'AL 1.00 FIX 16.20
OWNER: TEL -U 55 GAS REGULATOu 1.00 REG 75.20 FINAL DATE _ F; BY: ,CDE
CHENG JIAN H;DENG MEI 2BEN (626) 495-t;3.54- TOTAL FEES 157.35
4853 CAMELLIA AV
TEMP 917804241 DESCP,IP!!^ --i1— -----
IPLUMBING Flip THE ':DDITION
APPLICANT: TEL._--- _i-
SAME AS OWNER -
SPECIAL CCiMJi
i
ICCNi RACTOR: TEi.. Nf, J i AVPrOVALS - DA7E e 7ECTC'R SIGNATURE
SAME AS OWNER -
LIC, NO URUER SLAB '.'
- U2�� _,
WATER SSFi-'i✓—
APLASTIC 'f//N METAL :;"N
I ARC4ITECT OR
nlrl` _
HOT —WA—EF `Ii;�1T Gn_
__
PLUMBING FIn TUfi FE
LAWNCP Ens
GAS TES?
i UTi LITY COhir'ANY is^:TjfIE—DI
CWV
GRAY WRi ER 51'ST;1'. I �-----
REPORT ID: Dr"^26.i ROUTE TO: BSC508
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0305120019
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
BUILDING
TR: 14467 LT: 43 4853 CAMELLIA AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917804241
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LOWER AZUSA
8589-015-020 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY
47 WATER HEATER(S) 1.00 WTH 16.20
TOTAL FEES 43.95 ISSUED ON: PROCESSED BY: PLAN B EXP ON:
05/12/03 JK 11/08/03
OW TEL. NO: FINAL DATE FINAL BY: CODE:
CHENG JIAN H;DENG MEI ZHEN (626) 451-6718-
4853 CAMELLIA AVJ
TEMP 917804241 TSE PION Of WURK
C/O WATER HEATER
AP L. NO:
MARAVILLA FOUNDATION (323) 721-8881-
5729 UNION PACIFIC SPECIAL CONDITIONS:
COMMERCE 90022
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNA URE
MARAVILLA FOUNDATION (323) 721-8883-
5729 UNION PACIFIC LIC. NO UNDER SLAB WORK
COMMERCE, CA 90022 622969 C36
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: EL. .
ROUGHL
LIC. NO:
GAS PIPING
GAS N
Mr-gUfflEATER
PLUMBING FIXTURES
LAWN SPRINKLERS
GAS TEST
UTILITY COMPANY ED
CWV
GRAY WATER STEM
* ADDITIONAL DATA ON FILE
REPORT ID: DPR263 ROUTE TO: BS0508