HomeMy Public PortalAbout10924 DAINES DR_Plumbing__ WORKERS'COMPENSATION DECLARATION r >swacrA d n
1 herebyaffirm that I have a' certificate of consent to self cn 817 L2'.0) APPLICATION FOR PLUMBING. PERMIT 1ILJ1,
insure, or a certificate of Workers'Compensation Insurance,or - —� -
a certified copy thereof(Sec. 3800,Lab.C.)
., lrq� M�� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
�ertified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
RENS
Certified copy is filed with the county building inspection NUMBER FIXTURE ORITEMO FEE AD
department. WATER CLOSET LOCALITY TE vYI�L� C w
Date Applicant - .NEAREST A', 7�-y
BATH TUB CROSS ST. �s J 9
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - SHOWER OWNER /C Jif
LAVATORY - MAIL
(This section need not be completed if the work involved ADDRESS
by the permit is for one hundred dollars (3100) or less.) BINK - �'T -96sj 6
CITY TEL. NO. O
I certify that in the performance of the work for which this DISHWASHER y� / U
permit is issued, I shall not emplov any person in any manner CONTRACTOR /rr�T(���(� G 3 V4
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so as to become subject to the Workers' Compensation Laws CLOTHES WASHER ADDRESS F-
Date Applicant SWIMMING POOL RECEPTOR U
NOTICE TO APPLICANT: If, after making this Certificate of CITY 0/U�6U/A TEL. N0.,3�G�3� 0.
Exemption, you should become subject to the Workers' LAWN SPRINKLERSYSTEM
STATE `1 a LIC. �/� N
Compensation provisions of the Labor Code, you must forth- WATER HEATER LICENSE NO.,27 7 / CLASS if 20 Z
with comply with. such provisions or this permit shall be )
deemed revoked. GAS SYSTEM ! OUTLETS 00 DISTRICT NO. PROCESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER '
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code, and my license is in full force and DATE S Cr
effect. �3 Lic.Class. GZV FINAL AL
License Numbe T
Contractor
am exemptffr q.4� Plan check fee
1 am exempt rom the licensing requirements as I am a
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ 0
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
Lie.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name -
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section 7031.51 Busi- City T.I. No. -
ness and Professions Code):
I, as owner of the property, am exclusively contracting 6 9 2 A
with licensed contractors to construct the project
(Section 7044, Business and Professions Code).
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CONSTRUCTION LENDING AGENCY 2 � 11250
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is s _
issued(Sec. 3097,Civ.C.). `e o o 1 25-00
Lender's Name 10.26—Bl
Lender's Address
1 certify that I have read this application and state that the
above information is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
ab caned prop sty r insp ti a purposes.
—Signature ofy mtttee Date
COUNTY OF LOS ANGELES TEMPLE CITY k 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0607130009
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS; iv 3 t
TR: 10898 LT: 28 BL: B 10924 DAINES OR
FEE DESCRIPTION: QUANTITY: DOM: AMOUNT: TEMP CA 917802920
ASSESSOR INFORMATION NUMBER: NEAREST, CRQSS STREET:
8573-017-020 01 PERMIT ISSUANCE FEE 27.75 THOMAS-PAGE! 597 GRID: D3 LOCALITY.:,TEMPLE CITY, C
63 WATER PIPING BR/FIX 4.00 FIX 27.00
TENANT: 64 WATER PIPNG <= 1 1/2 1.00 LIN 16.20 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:-
TOTAL FEES 70.95 07/13/06 SK 01/09/07
OWNER: TEL. NO: ��^. -� r FINAL DATE FINAL BY: CODE:
MARKOFSKI MARY A (626) 443-9631- ✓.�` /
10924 DAINES DR ��, - -�'b n
TEMP 917802920 `; ^1I DESCRIPTION OF WORK
COPPER REPIPE, MAIN LINE
APPLICANT: TEL. NO:
KEVIN TRUETT (818) 505-8032-
5930 LAUREL CYN BL SPECIAL CONDITIONS:
N. HOLLYWOOD 91607
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
ULTIMATE PLUMBING (818) 505-8032-
5938 LAUREL CANYON BL LIC. NO •f•, UNDER SLAB WORK
N HOLLYWOOD CA 91607 734569C36 e �\
WATERSERVICE
PLASTIC YIN METAL YIN
ARCHITECT OR ENGINEER: TEL. NO:
ROUGH PLUMBING
LIC. NO:
GAS PIPING
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES
LAWN SPRINKLERS
GAS TEST
UTILITY COMPANY NOTIFIED
CWV
GRAY WATER SYSTEM
REPORT ID: DPR263 ROUTE TO: BS0508
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