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Home My Public Portal About5805 ENCINITA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION - APPLICATION PPLIC A TION FOR PLUMBING PERMIT I hereby,'affirm that I have a certificate of consent to self in- 20-0026 DPW ai90 P`i lr Ir IL '>esPri II IICI tll Ir IL tW YH9 Ytl PERMIT IR7tlB Y ^ Sure,or a certificate of Workers'Compensation Insurance,ora L ' certified copy thereof (Sec. 3800, Lab. C.) U . COUNTY OF LOS ANGELES DEPT..OF PUBLIC WORKS Policy No. 994965 Company RepIndemnity ❑ Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) SHO ENCINITA AVENUE (—Jy Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE ,LOCALITY 3 WATERCLOSET(TOILET) 5 TEMPLE CITY, CA Date ter Applicant NEAREST ' BATH TUBCROSS ST. _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE / SHOWER OWNER Hung Chou & Assoc. (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100) or less.) LAVATORY ADDRESS 2894 Larkfield Avenue I certify that in the performance of the work for which this per- SINK - / CITY TEL N mit is issued, I shall not employ any person in any manner so / Arcadia, CA c574-7267 as to become subject to the Workers'Compensation Laws. DISHWASHER S CONTRACTOR Frank Marrone & SORS, IPC ' Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING 100E RECEPTOR 9860 T nwpr Azusa Rd. emption, you should become subject to the Workers'Compen- CITY sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS El Monte 11`§)444-2548 ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. 397884 CLASS 36 C/1( LICENSED CONTRACTORS DECLARATION S - DISTRICT No. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS O i� 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION fect. 397884C/36 C/1 HOSE BIB DATE Y License Number Lia Class a FINAL O Contractor e F. Marrone & SOa& 12/31/92 BY F-1 - a - R I am exempt under Sec. Of~.1 B.&P.C. for this reason Plan check fee - a Date: sJ riC.CI °z Z 33- PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE' �J 11 1 7 oc SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant i ITF hereby affirm that I am exempt from the Contractor's LicenseName I fTy; =--_r •i}'_s Law for the following reason (Section 7031.5, Business andProfessions Code): Address CHECK ❑ I, as owner of the property, will do the work and the City Tel No. CHANGE structure is not intended or offered for sale(Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY LIL (IJ1 �i�" 2 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 t ' 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 ob e-ment'oned property for inspection purposes. G _ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of ermittee Date , COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1201030009 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: T TR: 46828 IT 1 UN: 4 5805 ENCINITA AV (FEE DESCRIPTION: QUANTITY: UOM: AM0UNT:1 TEMP CA 917802457 ASSESSOR INFORMATION NUMBER I I NEAREST CROSS STREET: 15300-017-D55 101 PERMIT ISSUANCE FEE _ 27.80 THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY, Cl 147 WATER HEATER(S) 1.00 WTH 116.30 TENANT: I TOTAL FEES 44.10 (ISSUED ON: PROCESSED BY: PLAN BY: 1 101/03/12 SR TOWNER: TEL. NO: FINAL DATE - FINAL BY: CODE: 15 T, ERNEST - 15805805 ENCINITA AV L ITEMP 917802457 - I (DESCRIPTION OF WORK REMOVE/REPLACE GAS WATER HEATER APPLI CANT: TEL. N0: ILUBA BATIDFF (425) 636-7084- ISPECIAL CONDITIONS: 11 .11 11 I (CONTRACTOR: TEL. NO: 1APPROVALS DATE INSPECTOR SIGNATURE IFAST WATER HEATER CO. (800) 454-8955- 1 112601 132 AVE NE LIC. NO 1UNDER SLAB WORK JKIRKLAND WA 90034 931237 C36 WATER SERVICE PLASTIC YIN METAL YIN (ARCHITECT OR ENGINEER: TEL. NO: - IROUGH PLUMBING LIC. NO: GAS PIPING 1 _ 1GAS VENT I I I I II I I I I IHOT WATER HEATER PLUMBING FIXTURES LA'n'N SPRINKLERS I1 T IcAs TEST I I I 1 I I I � (UTILITY COMPANY NOTIFTEDI I I IGS 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 11 I_ I I 11 I I I I I I I I I I I I I I I I I 1 I1` ADDITIONAL DATA ON FILE I I I I I I I II I I REPORT ID: DPF-253 ROUTE TO: BS0508 I I I I I I WOthat I have a certificate DECLARATION 76A667 DPW 9189 APPLICATION FOR PLUMBING PERMIT 2D-W26 I hereby affirm that I neve a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No. Company - f Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING C) G / Certified copy is tiled with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEMr@ FEE LOCALITY Date Applicant WATER CLOSET BATH TUB NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.W 4 COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) LAVATORY K OWNER C/ L tVV11"d I certify that in the performance of the work for which this permit MAILis issued, I shall not employ any person in any manner so as to SINK ADDRESS Z become subject to the Workers'Compensation Law DISWASHER CITY TEL.NO. p� Dale Applicant s. CLOTHES WASHER NOTICE TO APPL ANT: If, after making this Ce icate of CONTRACTOR Exemption, you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. } I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER IL (commencing with Section 7000 of Division 3 of the Business and STATE LIC. ( 9 ) LICENSE NO. CLASS U Professions Code, and my license is in full force and effect. GAS SYSTEM OUTLETS OUTLETS OVER DISTRICT NO. PROCESSED BY S 5 PER SYSTEM �-0� // � � Q License Number Lic.Class FI"AL VALIDATION DATE W a Contractor Date (n F-1I am exempt under Sec. BY FINAL rll4 •T ? B.BP.C.for this reason �L3 5, Date: Plan check fee - 1 IjGI is TOTAL PLUMBING PERMIT ISSUING FEE$ �, 7 ® SignatureEl 57 a 3�I TOTAL FEE CHECK 5-7.7i Plan check applicant SINGLE FAMILY 0 r_FIAN6E •ljQ 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 Professions Address 13 LA 941-el 4 Code): 0011 1—DCIII 1 7/ i3/� City � � Tel.No. ❑ I,as owner of the property,will do the work and the structure I L;