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Home My Public Portal About5805 1/2 ENCINITA AVE_Plumbing__ WORKER'Sv.aacertificate of 0-0026 76A66A 9/09 APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate el consent to self insure. or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3000 Lab.C:)" COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No. Company ❑ Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is tiled with the county building inspection ADDRESS department. NUMBER - FIXTURE OR ITEM @ FEE / •� LOCALITY (- Date Applicant WATER CLOSET NEAREST 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 PAGE PARCEL permit is for one hundred do 11 ars(3 100)or less.) LAVATORY OWNER G t f7e(o I certify that in the performance of the work for which this permit is issued, I shall not employ any person In any manner so as toSINK ADDRESS `L 1 AIL become subject to the Workers'Compensation Laws. DISWASHER CITYV' TEL.NO. Date _Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APP (CANT: It, after making this C tificate of GF Lr _L,x:') Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS provisions o1 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. Y I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER d (commencingwith Section 7000 o1 Division 3 of the Business and STATE LIC. Q ) GAS SYSTEM OUTLETS LICENSE NO. CLASS V Professions Cade,and my license is in full force and effect. OUTLETS OVER DIST U40. [ p PROCESSED BY Q S PER SYSTEM ��tG �,� 0 License Number Lic.ClassG p 7-.111 4 FINAL BB VALIDATION 57 W DATE -1 -Z J/.3C LU Contractor Dateto FNAL 1 ITEM Eti'. z F-11 am exempt under Sec. BIV _ B.BP.C.for this reason TOTAL 57 o :30_ Date: Plan check fee ® '-.HE';:{ PLUMBING PERMIT ISSUING FEE$ Q Signature CHANGE .1110 F-1 TOTAL FEE — 0 SINGLE FAMILY - Plan check applicant 001311-1110111 c- - HOME OWNER-BUILDER DECLARATION Name O (_f6 7 1 Art 4,:41 . I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address -L a - - Code): F-11, Tel. No. ' Z 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 T 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 far inspecti n purpo s. SEE REVERSE FOR EXPLANATORY LANGUAGE 7 _ �n t e o P ittee Date _WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING p UMBIN PERMIT hereby, pffirm that I have a certificate of consent to self in- J6A66jq PW 4190 Ir IL ILII/VIID OVi9 PERMIT �7 sure; or a certificate o>Workers'Compensation Insurance,oro certified copy thereof (Sec. 3800, Lab. C.) IILJII Policy No. 994965 Company Rep. Indemnity COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ❑ Certified copy is hereby furnished. - FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 58000ENCINITA AVENUE Certified copy is filed with the county building inspection ADDRESS .department. NUMBER FIXTURE OR ITEM (d FEE LOCALITY TEMPLE CITY, CA Date 6/24/93 Applicant WATER CLOSET(TOILET)- p 5 NEAREST - CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB / �Q CROSS ST. - COMPENSATION INSURANCE /- .SHOWER OWNER Hung Chou Assoc. (This section need not be completed if the work involved by - - MAIL 2894 Larkfield Avenue the permit is for one hundred dollars ($100)or less.) LAVATORY d ADDRESS I certify that in the performance of the work for which this per- / SINK CITY Arcadia, CA TEL NO574-72 7 mit is issued, I shall not employ any person in any manner so as to becomesubjectto the Workers'Compensation Laws. - DISHWASHER CONTRACTOR Frank Marrone & Sons, Inc Date Applicant CLOTHES WASHER ZY S3 ADDRESS NOTICE TO APPLICANT: If, after making this.Certificate of Ex- SWIMMING POOL RECEPTOR 9860 Lower Azusa Rd. empfion,you should become subject the Workers'Compem CITY E1 Monte `E$ '�444-254$ sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER JLICENSE NO. 397884 CLASS C/36 C/1 LICENSED CONTRACTORS DECLARATION M-3 DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM - OUTLETS9(commencing with Section 7000)of Division 3of the Business OUTLETS OVER5 PER SYSTEM VALIDATION and Professions Code, and my license is in full force and ef- FINALfect. HOSE 81B' DATE .R—�License Number 397884 Lic. Class C/:36 C/1a NAL C FI F. Marrone & Sons ' 12/31/92 FI v Contractor Date .- - cc ❑ I am exempt under Sec. F U 6.8 P.C. for this reason Plan Check fee W® d h Date: ,,PLUMBING PERMIT ISSUING FEE$ Signature _ - TOTAL FEE 5 SINGLE FAMILY - HOME OWNER-BUILDER DECLARATION - Plan check applicant j I herebyaffirm that I am exempt from the Contractor's License ,-'- P Name Law for the following reason (Section 7031.5, Business and Professions Code): Address - _((f •'3-�i�_i ElI, as owner of the property, will do the work and the City. .Tel. No. 9 T_rIC. structure is not intended or offered for sale(Section 7044, Business and and Professions Code). f'® - jf ,,P,L =v:x '..°..-.n CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency forCHANGE . ,i I_I the performance of the work for which this permit is issued - (Sec. 3097, Civ. C.). Lender's Name1 L'a. - IiI ii?I —4t�p�f ' } _4 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-mentis dd pr r inspection purposes. /✓Llj��„ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Dote