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HomeMy Public PortalAbout4840 CLOVERLY AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �t I hrtreby, offirrrz-that I have a certificate of consent to self in- 20-0026 DPW 4/87 76A667A .lure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) certified copy'thereof (Sec. 3800, Lab. C.) r COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company 0 Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) b Certified copy is filed with the county building inspection ADDRESS C /0 V4EQ L department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET(TOILET) TEM f� C17 Date Applicant NEAREST BATH TUB / CROSS ST. LQW�2 y�U,SA CERTIFICATE OF EXEMPTION FROM WORKERS' ;,COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work.for which this per- SINK mit is issued, I shall not employ any person in any manner so CITY TEL. NO. as to become subject to the Workers' Compensation Laws. DISHWASHER CONTRACTOR 6-6- 198 '6— ®B Date O Applicant LJeaG �-'" X` CLOTHES WASHER \ NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR ADDRESS emption,you should become subject to the Workers'Compen- CITY LAI TEL. NO. sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRO SSED PY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS -� �( 9(commencing.with Section 7000)of Division 3 of the Business OUTLETS OVER " (,J d Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL fe �`� VA ATION DATE O License Number Lic. Class (� FINAL Contractor Date BY O ❑ I am exempt under Sec. LU B.BP.C. for this reason pop. g Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ 2 9 7 8, 1 A Signature TOTAL FEE SINGLE FAMILY # o 0 0 0 0 5 HOME OWNER-BUILDER DECLARATION Rion check applicant. 2 2 5 O 1 hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and o 0 0 2 2 5 O 5 Professions Code): Address I, as owner of the property, will do the work and the City Tel. No. O 0 .�-8 8 structure is not intended or offered for sale(Section 7044, Business and Professions Code). pop- 'CONSTRUCTION '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 information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby a thorize representatives of this County to enter upon the a ove-mentioned property for inspection purposes. —$'Alp SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date /P �.wRKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 1 Rerrbyoaffirm that 1 have a certificate of consent to self 76A667A `raure }ar a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) © or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND D SAFETY Policy.No. Company Certified copy is hereby.furnished. ❑ BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS -/9 q0 6/OU e/I?C•' Certified copy is filed with the county building inspec- tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY DateApplicant WATER CLOSET NEAREST l CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. LOwG'✓ C�/ LCQc�ie2 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 less.) LAVATORY ADDRESS 'I G fU (!(0 0 EF,CL 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 CITY TEL. NO. so as to become subject to the Wor ers Compensation Laws. Ah Gt ��� _ DISHWASHER CONTRACTOR Date 11- y— $J Applicant """`�' CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY TEL. NO. p p y LAWN SPRINKLER SYSTEM with comply with such.provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT y O. t/ R ESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS l e' elJi (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER y and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL a�� VALID' TION DATE ^ 0 License Number Lic. Class FINAL/- E9 Contractor Date BYT, / 0 o ❑ I am exempt under Sec. `@" t� B.BP.C. for this reason r � Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ 0 Signature TOTAL FEE Plan check applicant 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 3 3 7,9 A Prof ssions Code): City Tel. No. I, as owner of the property, will do the work and the # 0 0 0 0 0 5 structure is not intended or offered for sale (Section , 7044, Business and Professions Code). ) o 0 2 &5 0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for o 0 0 2 5 0 c=� the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). ) 1,04-85 Lender's Name 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 ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the bove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date COUNTY OF LOS ANGELES TEMPLE CITY # 0508 CPLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS PSL 0508 9704230004 –BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA — ---` PHONE: (818) 285-0488 EXT: LEGAL ID: FEES PAID BUI.LD.ING-ADDRESS: TR: 11454 LT: 24 BL: .001 1�4840_CLOVERL.Y-AV- FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803808 ASSESSOR INFORMATION UMBER: NEAREST CROSS STREET: 8590-020-025 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J5 LOCALITY: TEMPLE CITY 07 BATHTUBS/SHOWERS 1.00 FIX 16.35 TENANT: TOTAL FEES 44.10 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 04/23/97 TC 04/23/98 OWNER: TEL. NO: FINAL DATE FINAL BY- CODE: ARVIZU WILLIAM;CARMEN (818) 287-4591- 4840 CLOVERLY AV TEMP 917803808 DESCRIPTION OF WORK ADD BATHTUB TO EXISTING LAUND ROOM TO MAKE FULL BATH APPLICANT: TEL. NO: 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 ARCHI ECT OR ENGINEER: TEL. NO: ROUGH PLUMBING LIC. NO: GAS PIPING GAS VENT HOT WATER HEATER s PLUMBING FIXTURES LAWN SPRINKLERS �\ L - GAS TEST UTILITY COMPANY NOTIFIED cWV GRAY WATER SYSTEM REPORT ID: DPR263 ROUTE TO: BS0508