HomeMy Public PortalAbout9021 EMPEROR AVE_Plumbing__ . 'WORKERS'COMPENSATION DECLARATION
t hereby affirm that I have a certificate of consent to self 76A667A) APPLICATION FOR PLUMBING PERMIT
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a r copy thereo/f"ec. 3800, Lob. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy p0.0 didCompany
�ElCertified copy is hereby furnished. BUILDING +
1 FOR APPLICANT TO FILL IN(PRINT OR TYPE) _
ADDRESS
Certified copy is filed with the county buil g inspec-. �
tiondeparim t. W (/� NUMBER FIXTURE OR ITEM ®' , FEE LOCALITY
Date Applicant WATER CLOSET -r 40 NEAREST
CER, IFICATE OF EXEMPTION FRO WOR RS
BATH TUB CROSS ST. Q ICY
COMPENSATION INSURANCE OWNER
SHOWER
(This section need not be completed if the work involved by
the permit is for one hundred dollars($100)or less.) �r LAVATORY ADDRESS
I certify that in the performance of the work for which this i
permit is issued, I shall not employ any person in any manner SINK +0 d 0 CITY /r TEL. 171-2
so as to become subject-)o the Workers'Compensation Laws. DISHWASHER
"� CONTRAC O
Date Applicant CLOTHES WASHER o0 ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
subject to t
you s
,
Exem tionhould become sub he Workers' SWIMMING POOL RECEPTOR
P Y I e1
";_Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM v CITY
w.ith.Omply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER UCENS O. CLASS
LICENSED CONTRACTORS DECLAPATION 06 DISTRICT NO. PROOC_ESSSEE'D' BY
GAS SYSTEM OUTLETS
I hereby affirm that I am licensed under prgvsions of Chapter 9 ?
(commencing with Section 7000) of Divis on'3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL J
DATE VALIDATION 0
License Number Lic. Class
FINA
Contractor Date BY
I am exempt under Sec.
B.$P.C. for this reason
Plan check fee --�-
Date:
PLUMBING PERMIT ISSUING FEE$ Q �l 16
Signature
TOTAL FEE ;
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License. `
Law for the following reason (Section 7031.5, Business and Address I s
Professions Code): City Tel. No.
❑ 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). n
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.). 1
Lender's Name �/ -
Lender's Address ��� V c!
I certify that'l have read this application and state that the
above information is correct. I agree to comply with all County
ordinan pop-
es and State laws regulating Plumbing, and hereby
authori re r ntatives of th s`County to enter upon the
bove- e 'o property f i 'e4Tkn purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o ermitt ' Da
f
r.
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0502030002
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 41245 LT: 1 UN: 9 9021 EMPEROR AV D
FEE DESCRIPTION: _ QUANTITY: UOM: AMOUNT: TEMP CA 917800000
ASSESSOR INFORMATION BER: NEAREST CROSS STREET: MUSCATEL
5382-011-038 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY, C
45 WATER CLOSET/URINAL 1.00 FIX 16.20
TE-WA-NT: TOTAL FEES 43.95 ISSUED ON: PROCESSED B : PLA BY: EXPIRES OW.--
02/03/05
.02/03/05 JK 08/02/05
OWNER: TEL. N0: FINAL DATE �� Y: CODE:
LEYTON, LILIANA (626) 291-5383-
9021 EMPEROR AV
TEMP 917800000 DESCRIPTION Of WORK
WATER HEATER CHANGE OUT
APPLICANT: E 0:
TEKAWA (310) 515-1311-
17111 S BROADWAY SPECIAL CONDITIONS:
GARDENA
CONTRACTOR: TEL. NO: i APPROVALS DATE INSPECTOR SIGNATURE
ACTION CONTRACTORS (310) 515-1311-
17111 SOUTH BROADWAY LIC. NO iUNDER SLAB WORK
GARDENA, CA 90248 652535BC36
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: TE 0: - i
ROUG PL MB NG
LIC. N0:
j
GAt PIPING
! VENT
HOT WATER HEATER
PLUMBING FIRTURES
LAWN SPRINKLERS
GAS TEST
UTILITY COMPANYMMIED
CW
GRAY WATER SYSTEM
REPORT ID: DPR263 ROUTE TO: BS0508