HomeMy Public PortalAbout5520 ENCINITA AVE_Plumbing__ ~ '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 8/86)
or a certified copy thereof (Sec 3800, Lab C )
Policy No Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS o
Certified copy is hereby furnished f
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING %
Certified copy is filed with the county building inspec- ADDRESS
tion department NUMBER FIXTURE OR ITEM @ FEE
LOCALITY ,
Dote Appli4ant WATER CLOSET � O NEAREST '
CERTIFICATE OF EXEMPTION FROM WORKERS' _ BATH TUB CROSS ST
COMPENSATION INSURANCEOWNER
SHOWER ' Y _
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less ) MAIL
LAVATORY ADDRESS dt
I certify that iii the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK O CITY TEL.NO
so as to becom subject to the W ers Compensation Laws
DISHWASHER' CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO A PLI NT If, after long ihis e c to of
Exemption; you should beco subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of th Labor Code you must forth- CITY TEL NO
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION ' DISTRICT NO PROCESSED Y
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVERy y,
and Professions Code,and my license is in full force and effect 5 PER SYSTEM FINAL
Z _ i- VALIDATIO A
License Number Lic Class DATE V
FINA cc
Contractor Date BY - 0
❑ I am exempt under Sec I0
61
B 8P C for this reason Plan check fee �
Date PLUMBING PERMIT ISSUING FEE$
S , ;277 �• A
Signature # a 0 0 0 0 5
TOTAL FEE 0
I � � 2&5,0
Plan check applicant
SINGLE FAMILY ;o o o Z a 5 0 5
HOME OWNER-BUILDER DECLARATION Name Z 0;-87
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031 5, Business and
Professions Code) I 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)
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 representatives of this County to enter upon the
ove-mentioned property for inspection purposes
r r SEE REVERSE FOR EXPLANATORY LANGUAGE
,tg ture of P i re —/ ate
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0311190004
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT:
L FEES PAID BUILDING S-
TR:_12410 LT: 20 5520 ENCINITA AV
I FEE DESCRIPTION• QUANTITY: UOM AMOUNT: TEMP CA 917802307
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET. BROADWAY
8588-002-020 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J4 LOCALITY. TEMPLE CITY
51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20
TENANT-: TOTAL FEES 43.95 ISSUED ON: PROCESSED : PLA I ON:
11/19/03 JK 05/17/04
OWNER: TEL NO FINAL D TE FINAL BY CODE•
PENG JAIME J (626) 795-8162-
SCRIPTION OF WORKC
GASLINE FOR NEW FURNACE
PLICA L. NO
AIR CARE (626) 442-6792-
10037 RUSH ST SPECIAL CONDITIONS.
S EL MONTE 91733
CONTRACTOR: TEL NO APPROVALS DATE INSPECTOR SIGNATURE
AIR CARE CO (626) 442-6792-
10037 RUSH STREET LIC NO UNDER SLAB WOR
SOUTH EL MONTE CA 91733 516562 B
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECTR ENGINEER: NO
ROUG4 PLUMBING
LIC NO I
GAS PIPING
GAS `ENT
OT WATER HEATER
PLUMBING FIXTURES
AWN SPRINKLERS
S TEST
UTILITY COMPANY
CW
GRAY, WATER SYSTEM
* ADDITIONAL DATA ON FILE `
REPORT ID• DPR263 ROUTE TO: SS0508
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