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Home My Public Portal About4503 ELLIS LN_Plumbing__ l WORKERS'COMPENSATION DECLARATION 76A667A I hereby,affirm that I have a certificate of consent to self CE fin (z-80) �P� L I CAT I ON FOR PLUMBING PERMIT insure, or a certificate of Workers'Compensation Insurance,or a Certified copy thereof(Sec. 3800,Lab.C.) 0e COUNTY OF LOS ANGELES BUILDING AND SAFETY b P�o-l�i/ No. o pany Sar L CJ ee- —q- AUt�u Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING @47 D �� ❑ ADDRESS g vJ� S Cer 'fied copy is filed with th ounty building inspection NUMBER FIXTURE OR ITEM O FEE d artment. WATER CLOSET LOCALITY Date' Applican Wim. - NEAREST d/} BATH TUB f'L.-t3Y� CROSS ST. VI d, C RTIFICATE OF EXE TION FROM WO KERS' COMPENSATION INSURANCE SHOWER OWNER /?eGA?MAIL R p LAVATORY 9Y ADDRESS f� (This section need not be completed if the work involved t�O by the permit is for one hundred dollars_($100)'or less.) SINK l.. O c� CITY ��c�— ' TEL. NO.�,- (� I certify that in the performance of the work for which this DISHWASHER o-6VfdV permit is issued, I shall not emp y an person in any manner 2 �� CONTRACTOR �� . , ��yI O so as t ,ec mmeisubject to th rke ompensation Laws. CLOTHES WASHER r��J� ADDRESS ~ Dater//d/ Applica "rr// SWIMMING POOL RECEPTOR a NOTI'E O APPLICAN after making is Certificate of CITY EL.NO to Exemption, you should b come subject to the: Workers" LAWN SPRINKLER SYSTEM STATE LIC. Z Compensation provisions of the Labor Code, you must forth- LICENSE NO CLASS e,"3&1 with comply with such provisions or this permit shall be WATER HEATER 'Z .fL✓ deemed revoked. GAS'SYSTEM OUTLETS ,t,a DISTRICT NO. PRO ESSl D BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER ✓� I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL ness and Professions Code, and my license is in full force and DATE % ( VALIDATION effect. FINAL License Num er� Lia Clas - BY Contractor !al Date lam exempt from the licensing requirements as I am a Plan Check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ t acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE �--7 v'✓ /• Lic.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name �� - I hereby affirm that I am exempt from the Contractor's Address ...- � 2.52 1. 3 A� License Law for the following reason (Section.7031.5, Busi- CityA T.I. No. � —5-p �" #,o'o 0 o'o'rj ness and Professions Code): 1, as owner of the property, am exclusively contracting 2 0 1 2 7,Q Q with licensed contractors to construct the project (Section 7044, Business and Professions Code). ° 0 1 '2 7,0 _ CONSTRUCTION LENDING AGENCY O S 1 1 -8 1 I hereby.affirm that there is a construction lending agency for the performance of the work for which this Qermit is issued(Sec. 3097i . Lender's Name p" i Ik �l)�/®" �+ '► ��.r�s'&&A7 y Lender's Address /QC E 51e Ab // T I 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 above- ntione property for inspection purpo es. Sigtrature ermitt6e Dated WORKERS'COMPENSATION DECLARATION w I hereby affirm that I have a certificate of consent to self CE 817 (i-86) A P PU C A T I O NFOR PLUMBING LUMBING PERMIT insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) ,,,, ,,�� . .I�.,e COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy Ngd��ompany Certified copy is hereby furnished. FOR APPLICANT TO FILL IN'(PRINT OR TYPE) BUILDING yy / ^ ADDRESS 0J D d �� O Ce' tified copy is-filed with the c unty building inspection NUMBER FIXTURE OR ITEM O FEE artrrgent. WATER CLOSET / �� LOCALITY L€ CI Dat 0 Applicant +� � NEAREST !-r0010 3 BATH TUB �F _00 CROSS ST. 779. (.�D CERTIFICATE OF EXEMP ON FROM WORKERS' / ,A COMPENSATION INSURANCE SHOWER OWNER MAIL (This section need not be completed if the work involved LAVATORY I dO ADDRESS ooS�Q-c� �t ei_ d . by the permit is for one hundred dollars ($100) or less.) SINK 0 '� CITY Aet TEL.NO.Lg? (� I certify that in the performance of the work for which this � � DISHWASHER e�, tr . permit is issued, I shall not emplq any person in any manner CONTRACTOR 5St p ♦v� le so as to 1)ecodie subject to th . kers' C06 irensation Laws. 3 CLOTHES WASHER !� ADDRESS 3�� 1�1� V67 ~ Date Applic SWIMMING POOL RECEPTOR ,,�t�, UJ NOTI E Td APPLICAN I after m g,this ertificate of CITY TEL. NO.gb,- �; Cn Exemption, you should come subject to he Workers' LAWN SPRINKLER SYSTEM STATE. fir' LIC. Z Compensation provisions o the Labor Code, you must forth- LICENSE NO. CLASSs�' 4J� with comply with such provisions or this permit shall be WATER HEATER 9 deemed revoked. ^ DISTRICT NO. PR CESSER BY y GAS SYSTEM A OUTLETS gry Q� LICENSED CONTRACTORS DECLARATION OUTLETS OVER -'®0 I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATION ness and Professions Code, and my license is in full force and DATE effect. C1 4-V FINAL License Number1-7Lia Class BY . Contractor S wffi pate I am exempt from the licensing requirements as I am a Plan check fee licensed architect or a registered professional-engineer PLUMBING PERMIT ISSUING:FEE$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE , C1710 Lie.or Reg,No. Date Plan check applicant HOME OWNER_BUILDER DECLARATION Name ASS 10 1 I->�1 r I hereby affirm that I am exempt from the. Contractor's Address 3 .25 2 1',2 R• License Law for the following reason (Section.7031.5, Busi- City JV Tel.No, ��j7 SG�� # o o•0 0 0 5 ness and Professions Code): I, as owner of the property, am exclusively contracting 2 0 0.9 7 00 with licensedcontractors to construct the project (Section 7044, Business and Professions Code). °i° ° 9 7 0 0'r-) CONSTRUCTION LENDING AGENCY 0 1 1 81 I hereby affirm that there is a construction lending agency for the performance of the 'work for wh'ch this permit is issued(Sec. 3097,Civ � Lender's Name �� tV r Lender's Address 01 ll�er _.w I certify that I have read this app ication 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 above- ntioned property for inspection purp)es. Sign ure of Permittee Date COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0208120022 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING D ESS: TR: 37582 UN: 9 4503 ELLIS LN FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917804250 ASSESSOR INFORMA ION NUMBER: NEAREST CROSS STREET: LOWER AZUSA 8592-001-055 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY 47 WATER HEATER(S) 1.00 WTH 16.20 TENANT: TOTAL FEES 43.95 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 08/12/02 JK 02/08/03 OWNER: TEL. NO: FINAL DATE �N BY: CODE: HERNANDEZ HECTOR X (626) 350-8067- / 4503 ELLIS LN TEMP 917804250 DESCRIPTION'OF WORK C/O WATER HEATER APPLICANT: TEL. NO: ACTION CONTRACTORS (310) 515-1311- 17111 S BROADWAY SPECIAL CONDITIONS: GARDENA 90248 CONTRACTOR: TEL. NO / �� 1 APPROVALS DATE INSPECTOR SIGNATURE ACTION CONTRACTORS (310) 515-1311- /�� % T 17111 SOUTH BROADWAY LIC. NO / �� \A�� UNDER SLAB WORK GARDENA CA 90248 B/L 27953,*. / .'� WATER SERVICE fi h �r-I, �� PLASTIC Y/N METAL.-Y./N ARCHITECT OR ENGINEER: TEL. N0: *,'; -_ Imo' ROUGH PLUMBING 1 LIC. No*; GAS PIPING - -- - _ --- -- - GAS VENT - I, � �'�� - �' • HOT WATER HEATER v. PLUMBING FIXTURES LAWN SPRINKLERS - GAS TEST ' ! UTILITY COMPANY NOTIFIED CWV GRAY WATER SYSTEM i * ADDITIONAL DATA ON FILE REPORT ID: DPR263 ROUTE TO: BS0508 /