HomeMy Public PortalAbout5019 ENCINITA AVE_Plumbing__ `4 Q
WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3800, Lab. ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NoCompany
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Le
Certified copy is filed with the county bui ing inspec- _
tion department. NUMBER FIXTURE OR ITEM @ FEE
n LOCALITY
Date % Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars ($100)or less.) MAIL
LAVATORY ADDRESS
I certify that in the performance of the work for whichthis
permit is issued, I shall not employ any person in any manner SINK .® CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTO
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of ,
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR —
CITY EL. NO.G�
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS _
LICENSED CONTRACTORS DECLARATION DISI T NO- PROCESSED BY
q OV
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
✓ �
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL V IDATION
yy���� QDATE
License Numbei.� � _5 Lic. Class
�n .® FI NA
Contractor Date— � BY % C, �
❑ I am a mpt under Sec. {
B.&P.C. for this reason Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ `
Signature J ;2 1 7 6 4 A
TOTAL FEE
# 000005 r
Plan check applicant
SINGLE FAMILY ( 0 o 9 4,5 0
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License o-o o 9 4,5 0 c=i
Law for the following reason (Section 7031.5, Business and Address
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the
structureis not intended or offered for sale (Section ,
7044, Business and Professions Code).
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.).
Lender's Name
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 ZPersm,'Itee
tatives of this County to enter upon the
above-meropertyfor inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign ure Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0208270009
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
ON FILE 5019 ENCINITA AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803708
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: PENTLAND
5388-009-007 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J5 LOCALITY: TEMPLE CITY
51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20
TENANT: 52 ADDN OUTLETS > 5 1.00 OUT 4.20 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
TOTAL FEES 48.15 08/27/02 JK 02/23/03
OWNER: TEL. NO: FINAL D TE FINAL BY: CODE:
SAN GABRIEL JAPANESE COMMUNITY CENT
5019 ENCINITA AV
TEMP 917803708 DE CR P ION OF W RK
GA LINES FOR CEILING FORCED AIR HEATERS
APPLICANT: TEL. NO:
ALOHA PLUMBING SHOP (323) 283-0018-
POBX729-777W MISSION SPECIAL CONDITIONS:
SAN GABRIEL 91778
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
ALOHA PLUMBING SHOP (323) 283-0018-
P.O.BOX 729-777 W MISSION RD LIC. NO UADEEP SLAB WORK
SAN GABRIEL, CA 91778-0729 440840 C36
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: TEL. NO:
ROUGH PLUMBING
LIC. NO:
GAS PIPING
GAS VENT
HAT WATER HEATER
PLUMBING FIXTURES
LAWN SPRINKLERS
GAS TEST
UTILITY COMPA2 NOTI IED !!9 ,�_oL rL—
cuv
GRAY WATER SYSTEM
Z/, -o L- 9 'o r
7TH
4" li 'e .4 e—
REPORT ID: DPR263 ROUTE TO: BS0508