HomeMy Public PortalAbout9821 DAINES DR_Plumbing__ DECLARA
ION
2"026
WORKER'S COMPENSATION
certificate
of consent
76A667 DPW 9,69 APPLICATION FOR PLUMBING PERMIT '
- 76A667A
I here4by affirm that I have a certificate of consent to self insure, ,-
or a certificate of Worker's Compensation Insurance, or a'certified
• copy thereof �Sec:3800 Lab.C.) - I
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.. .
Policy No. Company �y�
❑ Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS �t
department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY�� r
Date 1 2 T L Applicant — '� WATER CLOSETNEAREST
.
CERTIFICATED -EXEF�MPTION FROM WOR BATH TUB CROSS ST. _
COMPENSATION INSURANCE ASSESSOR ,q
Q1
MAP BOOK O .�. - PAGE1 Ery PARCEL O3
(This section;need not be comp- leted If the work involved by the SHOWER
permit is,for one hundred dollars($100)or less.) OWNER A _ 1
LAVATORY
I certify that in the performance of the work for which this permitMAIL r�
is issued, I shall not employ any person in any manner.so as to SINK' ADDRESS 2 r ,
become subject to the Workers' Compensation Laws.
DISWASHER CI�� TEL.NO.
Date Applicant CLOTHES WASHER' CONTRALTO
NOTICE TO APPLICANT: If, after making this Certificate of.. L
-Exemption,you shouldbecome subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the laboADDRESS Code, you must forthwith comply with such 4f
provisions or this permit.shall be deemed revoked. LAWN SPRINKLER SYSTEM V
�t0m/
LICENSED CONTRACTORS DECLARATION CITY TEL.NO.-7,1j,,_ }
hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER � r O
(commencing with Section 7000) of Division'3 of the Business and STATE
LICENSE,NO ���fl CLASS /�
Professions Code,and my license is in full force and effect. GAS,SYSTEM � OUTLETS ()
OUTLETS OVER
DISTRICT NO. PROCESSED BY
- - rr
y 5 PER SYSTEM Q
License Number A C��O Lic.Class 3 c U
FINAL /
DATE VALIDATION
Contractor k1a � ^—� - Date ACCT.•e (/)
,.
El am exempt under Sec. BY FINAL it(�� 112.1(,-
B.BP.C.'for this reason O ��" = 1 ITEMS
r Date: Plan check fee
PLUMBING PERMIT ISSUING FEE$ � ' TUTk 112 ® (35
TOTAL FEE
Signature `5 GHE{{�i •
11•, Q.
T-1 - 00
_
Plan check applicant C '
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name '
I hereby affirm that I am exempt from the Contractor's License Law „ , _• r� tt 4 q,y y ry
for the following reason (Section 7031.5,'Business and Professions Address M-0001
):
❑e City Tel.No. :.6787 1 ,—Aid 10 o 5? .
I, as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 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.) i T
Lender's Name —^
Lender's Address r
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 Co ty to enter upon the above-mentioned
property for inspection pu ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Date
COUNTY OF LOS ANGELES TEMPLE CITY- # 0508 - PLUMBING PERMIT .
DEPARTMENT OF PUBLIC WORKS ' 9701 LAS TUNAS PL 0508 1204180026 -
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
- PHONE: (626) 285-0488 EXT:
ILEGAL ID: 1 FEES PAID 1 BUILDING ADDRESS: 1
TR: 13805 LT: 64 1 1 9821 DAINES DR ?+
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA 917802637 1
(ASSESSOR INFORMATION NUMBER: I " 1 ` NEAREST CROSS STREET: BALDWIN 1
18588-016-039 - " ' " 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: '597 GRID: A3 LOCALITY: TEMPLE:CITY, Cl
- I _107 BATHTUBS/SHOWERS 1.00.FIX 16.20
(TENANT: 121 HOSE BIBB(S) 1".00 FIX - 16.-20 (ISSUED ON: PROCESSED BY: PLAN BY: 1
I 125 LAVATORIES/SINKS 1.00 FIX 16.20 104/18/12 SR I
I 145 WATER CLOSET/URINAL' 1.00 EIX 16.20 1 am% 1
T
IOWNER: TEL. NO: - 'TOTAL FEES 92.60 iFINAL DATE FSNAL'-BY:S I CODE:.. - i -
CONWAY-JOHN F;VIRGINIA"D : (626) 286-3913- if 11
r __ I
9821 DAINES DR
ITEMP 917802637 " ' - 1 - IDESCRIPTION OF WORK I .
I 11 BATHTUB, 1 HOSE BIBS, 1 LAVATORIE AND WATER CLOSET, i
1APPLICANT: TEL. N0: 1
ITSAI, WILLY (626), 281-5726- - - -
I - I ISPECIAL CONDITIONS: 1
1 1 1 1
(CONTRACTOR: - TEL. NO: 1 - IAPPROVALS DATE INSPECTOR SIGNATURE 1
PARTAIN'CONSTRUCTION (626) 281-5726- I I
1326 BELLA VISTA LIC. NO 1 (UNDER SLAB WORK I
IMONROVIA, CA 91016 950949 B
I (WATER SERVICE I I
I 1PLASTIC Y/N METAL Y/N 1 I I
1ARCHITECT OR ENGINEER: TEL. NO: I I I I
ITSAI, WILLY• (626) 281-5726- 1 (ROUGH PLUMBING - I I
1 236 S ATLANTIC BLVD _ .LIC. NO:.)
IALHAMBRA CA 91803 950949 B * 1 - .(GAS PIPING I - I
I I IGAS VENT
I IHOT WATER HEATER " 1 1 I
-
I _ I IPLUMBING FIXTURES I I '
I ILAWN SPRINKLERS- I' I
I I IGAS TEST I i i.
I - - I (UTILITY COMPANY NOTIFIEDI I _
I I I I I I
1 1 I CWV
I I I I I I
I' I IGRAY WATER SYSTEM
I• . I I .
• I - ." I I I I I
1 1* ADDITIONAL DATA ON FILE 1 I I I
I I I I I I
I IREPORT ID: DPR263 ROUTE TO: BS0508 I I I I
I I I I I I