HomeMy Public PortalAbout10527 DAINES DR_Plumbing__ 76A667-CE817 6-60 21
APPLICATION FOR UMBING PERMIT
COUNTY OF
CUNGINEER
BUILDING AND SAFETY DMSION BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS 10527
Daines Dr-
WILLIAM A JENSEN, SUPT OF BUILDING LOCALITY Temple City
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM
OWNER
WATER CLOSET
BATH TUB ADDRESS 10217 Lower Azusa d
sxowEa
CITY Temple ity TEL NO.
'2— LAVATORY CONTRACTOR Cavanaugh Plumbing
/ SINK ADDRESS P.O. Box 205
DISHWASHER CITY Chino TEL. NO.
Y STATE ❑
LAUNDRY TUB REGISTRATION NO. Is /6- COUNTY
CLOTHES WASHER DISTRICT NO GROUP ZONE I PR CESSED BY
WATER HEATER U^�QA Tal
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL
INSPECTION RECORD
Y -
a
O
U
94
O
� U .
W
P. -
Q $1.00 PER ITEM /,y�
OR FIXTURE $ ( v / APPROVALS D TE INSPE TOR'S SIGNATURE
PERMIT $ 200 UNDER SLAB WORK G'! ?S
TOTAL FEE ,i ROUGH PLUMBING
GAS PIPING
1HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT p /cif /.,�.�•�'/
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING HOT WATER HEATER
o`
1 HEREBY CERTIFY THAT I A PROPERLY REGISTERED AHD/OR PLUMBING FIXTURES 6llI 1! 1
LICENSED AS REQUIRED BY LO ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THAT 1 E LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDE NTIA TY UTILITY CO NOTIFIED
SIGNATURE
OF PERMITTE FINAL
®r �A.LIDATION ROBERT A WOOD,
® 0 CAgR SUPERVISING MECHANICAL ENG'R
b 1 Sit' 7 5 D
12 ,00
WORKERS' COMPENSATION'DECLARATION APPLICATION- FOR` PLUMBING PERMIT
�J '-. ,20-0026 DPW 4/87 r
t1 he'el,, offirmihat l hive,a cehtficate,of consent to'self°in- 76A667A " P
/• ure, or a cert&t-6`te of Workers'Compensation Insurance,or a CE 817(REV 8%86)
certified copy thereof,(Sec 3800, Lab C') 11
_ -
COUNTY OF LOS ANGELES DEPT. OF,PUBLIC WORKS ;b
Policy Nd, 33 ComiZany (;oWl � oY!
ny'�QJ 3 -
' `Certified copy is;hereby'furnished iUlyUhdflf.� My
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING � 27 �a i�� �lry
:.Certified copy is filed with the,county building inspection _ ADDRESS / y {`
udepartment. NUMBER FIXTURE OR,ITEM _(a 'IFEE
w LOCALITY
Date Applicant WATER CLOSET(TOILET) NEARE
ST' 1
' ',CERTIFICATE OF EXEMPTION FROM WORKERS' ° BATH TUB. - CROSS ST �,"111 iV I VI A ✓e'
^• ,r` COMPENSATION INSURANCE . . } SHOWER OWNER ��
(This section'need riot be completed if the work involved by MAIL h /-�
the permit is-for one hundred dollafs ($100)or less ), LAVATORY, r ADDRESS l�S Z G //'a;�J�'s;v f!
. ` rs.
d certify that in the perform'ance''of the'voikOfor-which this per- SINK �e •G f
mit is issued, I'shall not employ any person in ariy'manner so r' CITY - Two TEL NO 848�/j�jf;_ 3'73
as,to become sublect to the Workers' Compensation Laws
.rn i ori :c' DISHWASHER �U CONTRACTOR
Dater* µ' 4'y A Applicant k "CLOTHES WASHER
NOTICE TO APPLICANT If,_afte'r•making this,Ce2-r—_rtificate of Ex' ADDRESS �j�j"� [/�V/, ���/� a emption,youu should become sublect to the Workers' SWIMMING POOL RECEPTOR Compen- - - )
sationprovis'ions,oftheLaborCode', you'musfforthwith"comp=r- i CITYo-�.iLl,l�-C�T; TEL,NO X13-3Pj6;-
LAWN-SPRINKLER SYSTEM `^', Temp,�!
1y'hth,`such;prodisidns or this permir'shall be deemed revok- - STATE
ed ' -'. LICENSE NO LIC'SS
$6
LICENSED CONTRACTORS DECLARATION r WATER HEATER �77 7
x DISTRI NO, P ESSED'BY
' I hereby affirm that'l-am licensed under provisions of Chapter _ GAS SYSTEM OUTLETS
9(commencing°with Section 7000)of Division 3 of the Business OUTLETS OVER =
and Professions Code,'and my license
DATE is in full force and ef- 5 PER SYSTEM x FINAL V DATION,
feet - z° ' I '`' "
b Z = 0
License Nuh ber o� ��7`�• L'ic class
� (�
-
Contractor BY
- T� - O /I O
Date '
0- I am exempt under Sec .11
B'&P C_ for this reason
�` t. w Plan check fee, ► a
Date PLUMBING PERMIT ISSUIN'G`FEE $ -
Signature
_ - - TOTAL FEE,_ ' �0 t x g 7'&'19 FI
SINGLE FAMILY '
HOME OWNER-BUILDER DECLARATION' Plan cKeck applicant'
I hereby affirm that I am exempt from'the Contractor's License Nome
Law:for_the followmg;„reason (Section 7031 5,,Business.and -28 5:0
Professions Code) Address
- 28.5d'
+'1,4as owner of the property, will do the'work and'the City ` �� k ,T,el No' -� 7 g, n t
T structure is not intended or offered,for sale(Section 7044, / it 'I 603,4.88
'4w Business bind Professions Code) ;
CONSTRUCTION LENDING AGENCY 4 y r
I hereby affirm that is a'construction lending'agency for
th"'performance of the work for which'this permit is issued
(Sec 3097, Civ•C ) 1
Lender's Name
Lender's'Address
I ceihfy that'l have read thi's.opplication and state that-the'
above information is'correct I agree to'comply wrth all County' �" n
ordinances dnd-State laws regulating Plumbing,,and hereby "
authorize representatives`of_this County to enter upon the + 1• v�'*.
abov -men tioneZ��
nspection purposes =< a
SEE REVERSE FOR'EXPLANATORY LANGUAGE
Signature bate
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0606020012
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
LEGAL ID FEES PAID BUILDING ADDRESS
TR 11695 LT 9 BL B 10527 DAINES DR
FEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917802813
ASSESSOR INFORMATION NUMBER NEAREST_ CROSS STREET HALIFAX
8586-011-024 01 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 597 GRID C3 LOCALITY TEMPLE CITY, C
45 WATER CLOSET/URINAL 1 00 FIX 16 20
TENANT TOTAL FEES 43 95 ISSUED ON PROCESSED BY PLAN BY EXPIRES ON
06/02/06 JK 11/29/06
OWNER TEL NO z FINA, DA I
� BY CODE
KWON CHONG SU,KI WON (562) 547-8860-
10527 DAINES DR
t:Lj
TEMP 917802813 DESCRIPTrW OF WORK
�- WATER HEATER CHANGE OUT
APPLICANT TEL NO
TEKAWA (310) 515-1311-
17111 S BROADWAY SPECIAL CONDITIONS
GARDENA, CA 90248 1
CONTRACTOR- TEL NO APPROVALS DATE INSPECTOR SIGNATURE
ACTION CONTRACTORS, INC (310) 515-1311-
17111 S BROADWAY LIC NO _ UNDER SLAB WORK
GARDENA, CA 91248 65253SBC36
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER TEL NO
ROUGH PLUMBING
LIC NO
GAS nIPING
1
GAS VENT
HOT 'TATER HEATER
PLUM9ING FIXTURES
LAWN SPRINKLERS
GAS EST
UTIL.TY COMPANY NOTIFIED
CWV
GRAY WATER SYSTEM
REPORT ID DPR263 ROUTE TO BS0508