HomeMy Public PortalAbout9075 EMPEROR AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 7ewee7w
I hereby affirm that I have a certificate of consent to self cE e» (z-eo) APPLICATION FOR PLUMBING PERMIT .
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.)
COUNTY OF LOS ANGE LE B MING, ZA D'SAFETY
Policy No. Company
D Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING,-,2,
Certified co is filed th a count �uildingNUMBER FIXTURE OR ITEM • FEE ADDRESS . Jpy y inspection
department.- 7 LOCALITY
ate` 1 Applicant �� WATER CLOSET �d NEAREST
BATH TUB OZ CROSS ST.
CERTIFICATE OF EXEMPTION F OM WORKERS' '
COMPENSATION INSURANCE SHOWER _ �� OWNER
f MAIL
(This 'section need not be completed if the work involved LAVATORY l al3U ADDRESS
by the permit is for one hundred dollars ($100) or less.)
SINK CITY a.
O
I certify that in the performance of the work for which this DISHWASHERU
permit is issued, I shall not employ any person in any manner ✓�G" CONTRAC r syr `jam ��J
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER ' G ADD tX
/ . t- O
Date Applicant U
SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT: If, after making this Certificate of CIT E 14 J3 TE J � Ul
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE / CLASS
LIC.
LICENSE NO.
Compensation provisions of the Labor Code, you must forth- 1
with comply with such provisions or this permit shall be WATER HEATER �y j�l 6e
deemed revoked. DISTRICT NO. P OC SED BY
GAS SYSTEM OUTLETS �� r �, �
LICENSED CONTRACTORS DECLARATION OUTLETS OVER iZiGZ r!i�
I hereby affirm that I am licensed under provisions of Chapter 5 PE R SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL
ness and Professions Code, and my license is in full force and DATE VALIDATION
effect.
+'i 1�' / ^� � ] FINAL
License Number o�J• �j(O `I;ia Class 4��p- BY _
Contractor r _Date
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
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
License Law for.the following reason (Section.7031.5, Busi- City Tel.No.
ness and Professions Code):
D `
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project �9 4 4 2 7 A
(Section 7044, Business and Professions Code). !f 5
0 0 0 0
CONSTRUCTION LENDING AGENCY o - 49, 00
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.). :° ° 049,005
Lender's Name
0317-81
Lender's Address
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
thorize representativ s of this County to enter upon the
above- entioneci,-pro erty for inspection purposes.
si naure of Pa ittee Date
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COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1201310001
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID 1 BUILDING ADDRESS: 1
ON FILE I 1 9075 EMPEROR AV 1
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 SGAB CA 917752016 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: 1
15382-012-037 101 PERMIT ISSUANCE FEE 27.80 1 THOMAS PAGE: 596 GRID: H1 LOCALITY: TEMPLE CITY, Cl
125 LAVATORIES/SINKS 1.00 FIX 16.30 1 I
(TENANT: I TOTAL FEES 44.10 1015ON: PROCESSED BY: PLAN BY:
31/l
(OWNER: TEL. NO: I 1FINAL DATE FINAL BY: CODE: 1
ICHENG, PAUL (626) 372-9180- 1 _
19075 EMPEROR AV 1 1 3 -'� I
ISGAB 917752016 IDESCRI TION OF WORK
1 (REPLACE KITCHEN SINK
1APPLICANT: TEL. NO: I I I
ISAME AS OWNER I I I
I I (SPECIAL CONDITIONS: I
i 1 I PPR VAL DATE INSPECTOR SIGNATURE 1
1CONTRACTOR. TEL. NO: 1 IA 0 S I
SAME AS OWNER -
I
LIC. NO (UNDER SLAB WORK I I I
I I (WATER SERVICE I I I
I I IPLASTIC Y/N METAL Y/N I I I
(ARCHITECT OR ENGINEER: TEL. NO: 1 I I I I
I - I (ROUGH PLUMBING I 1 I
LIC. NO: I I I I I
I IGAS PIPING
I IGAS VENT I
IHOT WATER HEATER I I I
I I 1PLUMBING FIXTURES I I I
1 I (LAWN SPRINKLERS I 1 I
1 I IGAS TEST I I
I (UTILITY COMPANY NOTIFIEDI I
I I ICWV I I
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
1 1 I I I I
I (REPORT ID: DPR263 ROUTE TO: BS0508 I I I I
I I I I I I