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Home My Public Portal About4906 ENCINITA AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 20 0026 DPW 9/69 76A667A APPLICATION FOR PLUMBING PERMIT 76A667 I hereby affirm that I have a certificatj? of consent-to self insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec 3800 Lab C) 75 Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV Certified copy is hereby furnished BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS �f t N�� Certified copy is filed with the county building inspection depart ent NUMBER FIXTURE OR ITEM @ FEE I r� LOCALITY ��i_3-�I 5- Date ApplicantClAqWATER CLOSET NEAREST C•�'' _5 CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGEd PARCELU' 11 permit is for one hundred dollars($100)or less) LAVATORY Csy OWNER I certify that in the performance of the work for which this permit 6 l/ is issued, I shall not employ any person in any manner so as to / SINK MAIL A G become subject to the Workers' Compensation Laws ADDRESS `DC7 DISWASHER D cl:Yrr TEL NO Date Applicant CLOTHES WASHER cw NOTICE TO APPLICANT If, after making this Certificate of CONTRACTOR—rom i91 Exemption, you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with,such ADDRESS provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM {� LICENSED CONTRACTORS DECLARATION WATER HEATER CI TEL NO [�-'� t I hereby affirm that I am licensed under provisions of Chapter 9 ;457<707 cL0 (commencing with Section 7000) of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO CLASS Professions Code,and my license is in full force and effect 0 V OUTLETS OVER �RIi�TRbCN� PROCES BY Q5 PER SYSTEM i-� X iOLicense Number ,_Lic Class CCCJJJ I_ �+ FINAL DAT A/— VALID ION WW CL Contractor Date N ❑ I am exempt under Sec BY AL _ ? B&P C for this reason ` Date Plan check fee , Signature PLUMBING PERMIT ISSUING FEE$ _L3 IV � ❑ , _ TOTAL FEE SINGLE FAMILY Plan check applicant �rT HOME OWNER-BUILDER DECLARATION Name ACL s.v I hereby affirm that I am exempt from the Contractor's License Law ��t�1 65.50 , �- for the following reason`(Section 7031 5 Business and Professions Address '�0 65.Ul-I Code) ❑ i City Tel No I ITEM I, as owner of the property,will do the work and the structure TOTAL � � is not intended or offered for sale (Section 7044, Business 65 e® — 0 and Professions Code) , C HEC l r we — CONSTRUCTION LENDING AGENCY ,[II_! I hereby affirm that there is a construction lending agency for the / CHANGE performance of the work for which this permit is issued (Sec 3097, Civ C) Lender's Name 2411 M 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 ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PCUMBING-PERMIT--- DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS PL_0508 9710090016" BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA PHONE: (818) 285-0488 EXT: -LEGAL TR: 1238 LT: 110 (4906 ENCINITA-AV* FEE DESCRIPTION: QUANTITY: UOM: AMOUNT- TEMP CA 917803705 ASSESSOR N B : NEAREST CROSS STREET: 8590-030-011 01 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE- 596 GRID: J5 LOCALITY: TEMPLE CITY 51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.35 i TOTAL FEES 44.10 ISSUED 0 EXPIRES 10/09/97 UT 10/09/9 OWNER: TEL. NO: FINAL DATE FINAL BY: DE: HALL RICHARD J;LINDA (818) 285-6653- (�,tl 4906 ENCINITA AV TEMP 917803705 S I GAS LINE FO NEW HEATING AND Al NDITIONING SYSTEM AP CONNOR AIR CONDITIONING (626) 285-6653- SPECIAL CONDITIONS: LE&_� CONTRACTOR: TEL. NO - APPROVALS DATE INSPECTOR SIGNATUR CONNOR AIR CONDITIONING AND REFRIG. (818) 286-3157- 4931 NORTH ENCINITA LIC. NO UNDER SLAB WORK TEMPLE CITY, CA 91780 C20 & C38 * I WATER SERVICE O ARCHITECT OR ENGINEER: PLASTIC Y/N METAL Y/N `fes/ ROUGH PLUMBING LIC. N0: ttt � GAS PIPING US VENT ED �Q� O�QQ�S OT GA WATERHEATER 0 0- PLUMBING FIXTURES �n WN SPRINKLERT O cs TEST UTIQ L 1Y COMPANY NOTIFIEU GRAY WATERSYSTEM * ADDITIONAL DATA ON FILE REPORT ID: DPR263 ROUTE TO: BS0508