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COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0806050018
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
ILEGAL ID I FEES PAID I BUILDING ADDRESS
ITR. 13805 LT- 84 I I 9914 DAINES DR
I , IFEE DESCRIPTION QUANTITY DOM AMOUNT I TEMP CA 917802638 1
(ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET 1
18588-018-016 101 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE. 597 GRID A3 LOCALITY TEMPLE CITY, Cl
1 151 LOW PRS GAS 5 OUTLET 1 00 SYS 16.20 1 1
ITENANT I TOTAL FEES 43 95 (ISSUED ON PROCESSED BY PLAN BY EXPIRES ON I
I 106/05/08 SR 12/02/08 1
(OWNER TEL NO IFI D TE� FIJIA BY CODE
I FAILING DOUGLAS
172 WINNIE WA
IARCD 910078047 I IDESCRIPTION OF WORK 1
I IGAS MAIN -
I
(APPLICANT TEL NO 1 I
IS.O S. PLUMBING (626) 859-0301- I I
1729 E ARROW HWY. I ISPECIAL CONDITIONS. 1
IAZUSA, CA 91702
I I I I
I I I I
ICONTRACTOR TEL NO I (APPROVALS DATE INSPECTOR SIGNATURE 1
IS 0 S PLUMBING (626) 859-0301- I 1 I
1729 E ARROW HIGHWAY LIC NO 1 1UNDER SLAB WORK I I 1
IAZUSA, CA 91702 693502 C36 11 r 1-1
I WATEeR SERVICE I I
I IPLASTIC Y/N METAL Y/N
(ARCHITECT OR ENGINEER TEL NO I - _ I -
I I IROUGH PLUMBING 1 1 1
LIC. NO I I-- I
1 1 IGAS 'IPING
1 1 I GAS.VENT Ic I I
l I 1 I I I
I IHOT WATER HEATER I
I I I
1 I 1PLUMBING FIXTURES
I I I I I I
1 — ILAWN SPRINKLERS I I I
I I I I I I
IGAS TEST I I I
I I 1 1 1
I 1UTILITY COMPANY NOTIFIEDI I I
I I I
ICWV
I I
IGRAY WATER SYSTEM
I I I I I I
I I I I I I
I I I I I I
I I I f I I I
I I I I I I
I I I I I I
I IREPORT ID. DPR263 ROUTE TO- BSO508 I I I
I I I I I I
DRKERS'COMPENSATION DECLARATION,t +
r• '• 20-0026 DPW 4/87 ; APPLICATIOWFOR. PL=UMBING- RMIT' ' ;
1.hereby, r,ren that I hove'a certificate of•consent to,self in- 76A667A K
sure,or a certificate of Workers'Compensation Insurance,ora'. CE_817(REV 8/86) x`L> - '� s '•
certified copy thereof (Sec 3800, Lab .0 ) . -,
Policy No s COUNTY-,OF'.LOS ANGELES ,'j DEPT; OF PUBLIC WORKS t'
y "ampanY'' �'" ����1) �L�� �•
Oerhfied copy by furnished , , °' ••
v FOR=APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county build�mg,mspechon ADDRESS'
°departure"nt ",t• ' NUMBER .,_FIXTURE OR ITEM. Lla FEE
LOCALITY
s DDdtea' w as A hcant /1—^'�/h - WATER CLOSET(TOILET)
PP NEAREST ?" ,'� _ "
CERTIFICATE;OF EXEMPTION FROM WORKERS' _ { BATHjTUB, .CROSS.ST`
COMPENSATION INSURANCE' ,f r . - SHOWER `wJ d OWNER'
t r - "Al
(This section need not be completed if,the,work^involved by , MAIL /,i
the permit is-for o_ne hundred dollars (5100)or less.) v LAVATORY - = ADDRESS 7
kcertify-th5t in the performance of the work for wl ici this per e "
SINK '�Q CITY^ /•-� TEL' NO
mit is.issued,'I shall not employ any person,i'n,any.rrianner'so ('' �'
••,ds•to become'lsublect to the Wotkers'Compensation Laws = .
N , t 1.' 1
DISHWASHER -
i >r CONTRACTOR e t
Date' '' ' `Applicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT If,-af,ter'making•thi's Certificate of Ex- �:'
emphon, you should,become subject to the-Workers'Compen- SWIMMING1POOL RECEPTOR '
CITY; TEL
satioriLprovisions of the Cabor,Code;"you-must forihwith,comp_ LAWN-SPRINKLER SYSTEM;
ly'with such provisions'or,this permit-shall be deerried;reyok, STATE UC
ed4'': :`� ^-� - " ' - .p,.`^ n 'WATER HEATER - _ - ir)� LICENSE.NO• 1, `f'" L ' CLASS
LICENSED-CONTRACTORS DECLARATION V7 DISTRICT ROCES�ED BY
" GAS SYSTEM,- OUTLETS
I,hereby'affirm'that I'am licensed under provisions of.Chapter,•, , - ., � -
.9'(commenang'with Section 7000)'of Division 3 of the,Business x' OUTLETS OVER• s ��'`�' 1
and P`rofessions;Code' and m license is m`fulI force and of-.• 5 PER,SYSTEM'-
v - FINAL` - VALIDATION
DATE C
License Numb'er ��`�'� ZLic''Class - -• - - - - -
FI sEi�l rs
'Contractor (' ' tri " ''Date'' j ] Y '
'I am.exempt under Sec i W
tom.'i i %.' U
&P%C'for this reason, F ;Planrcheck.fee.," ; ;�! 5. ., o°f •m 150,Z
7 Date PLUMBING PERMIT ISSUING FEET$ �� i E
Signature ti`_ s j ``' _ { r TOTAL FEE ,3 f.laF?s`3 , w ��IIU
.r• ' SINGLE'FAMILY '•• Plan'check,applicant K
77
--HOME OWNER-BUILDER DECLARATION -"�5.
I her`ebyzaffirm that.l'am exempt from the Contractor's License Name n ✓, r— k"=i iy
Law for ,the following •reasona(Se_ction 7031-'5, Business and:. ��7��T T02 ;��1..i�-�=
Professions Code) Address', vU, ` .1 W�� �, t' "1;s'} f; ll ',�ft
O•, I;.as ownervof the property, Wilk do•the tvvark and"th'e Gty42 S7 od8
structure is not intended or offered for'sal"e'(Section 7044;
Business and Professions Code)' +
CONSTRUCTION LENDINGAGENCY
Thereby affirm lhat,the-re•,s 5•construction,lending.agency for a` •t ?
tR'e performance of
work for which,tF is permit is issued
(Sec 3097,Ctv C )
.N � , fg , i . , •�..rye r - ': a _ - ,.� a r,,.• � _ _ - •
L'ender's Namew.
Lender's Address ;
I,certrf_y;that I have r- this application and state that the
above information is correct' I agree•to comply witH all County r ''" - ;,�; 't
ordinances and'State•laws regulating Plumbing, and hereby
authorize representatives of this County to'enter upon the
abov ent ned property form echon purposes y.
SEE REVERSE FOR EXPLANATORY LANGUAGE ;
' ,•_ i
Signdture"of Per' tee D e ='t •• �" _