HomeMy Public PortalAbout4943 FIESTA AVE_Plumbing__ WORKER'SCOMPENSATION DECLARATION 20-0026 DPW 9/89 APPLICATION FOR PLUMBING PERMIT ll
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S hereby'affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec. 3800 Lab. C.)
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ComGyV� COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF( PUBLIC WORKS DIV.
Policy No. ,
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS � �`
Certified copy is filed with the county building inspection
department. f_ NUMBER FIXTURE OR ITEM Q FEE LOCALITY
L
Date 12 i Applicant �/. V. � 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 Zi. SHOWER MAP BOOK C'Q PAGE,��5/0/ I PARCEL p23
permit is for one hundred dollars($100)or less.) OWNER ��
I certify that in the performance of the work for which this permit LAVATORY,
is issued, I shall not employ any person in any manner so as to SINK MAIL 2Q
ADDRESS
become subject to the Workers'Compensation Laws.
DISWASHER CITY � W TEL.NO.
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked. AWN SPRINKLER SYST M
LICENSED CONTRACTORS DECLARATION; CITY TEL.NO. �71��� >_I hereby affirm that I am licensed under provisions of Chapter 9 7/� WATER HEATER _ CL
(commencing with Section 7000) of Division 3 of the Business and LICO
LICENSE NO. CLASS
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS Q V
OUTLETSOVER DISTRICT NO. PROCESSED BY ('L
5 PER SYSTEM Q
License Number Lic.ClassFINAL
_ !/ V
T r^ DATE ���/�.s! VALIDAION a-
Contractor �/ Date `� l 'l -s CD
❑ I am exempt under Sec. FFIINAL
4A _T.
E
B.&P.C.for this reason
Plan check feeOLZ
a _
Signature PLUMBING PERMIT ISSUING FEE$ 'r
❑ TOTAL FEE 1-111 r='.3)_ n t€ t
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Namet
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(,_ s�i
I hereby affirm that I am exempt from'the Contractor's License Law -'^^
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for the following reason (Section 7031.5, Business and Professions Address { _ i E i N :,
Code):
❑ 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 Y ��-
Lender's Address
I certify that 1 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 pur o e SEE REVERSE FOR EXPLANATORY LANGUAGE
SIgnat4 of Permit ee Ddie
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS PL_0508_98082-10014-j
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL ID: FEES PAID BUI.LD.I.NG_ADDRESS:
TR: 11454 LT: 41 04943 FIESTA AV _ �_
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP—CA 917803817
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LOWER AZUSA
8590-019-023 01 PERMIT ISSUANCE. FEE 27.75 THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY
07 BATHTUBS/SHOWERS 1.00 FIX 16.20
TENANT: 21 HOSE BIBB(S) 1.00 FIX 16.20 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
25 LAVATORIES/SINKS 1.00 FIX 16.20 08/21/98 UT 08/21
45 WATER CLOSET/URINAL 1.00 FIX 16.20
OWNER: TEL. NO: 47 WATER HEATER(S) 1.00 WTH 20 FINAL DATE FINAL BY- CODE:
TRINH TONY;LAM KELLY 51 LOW PRS GAS 5 OUTLET 1.00 SYS 6.
4943 FIESTA AV TOTAL FEES 124.95 Z'
TEMP 917803817 DESCRIPTION OF-WORK -_
r— PLUMBING FOR GUEST HOUSE --
APPLICANT: TEL. NO:
NGUYEN (626) 918-8906-
1139 GLENVIEW RD. SPECIAL CONDITIONS:
WEST COVINA, CA E
CONTRACTOR: TEL. NO: 9OC APPROVALS DATE INSPECTOR SIGNATURE
REACH CONSTRUCTION (818) 282-0042- �/\ �j�
419 N. ATLANTIC BLVD., #207 LIC. NO UNDER SLAB WORK ' s
MONTEREY PARK, CA 91754 6957538 G /� WATER SERVICEG
v PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: TEL. NO: O Z / K�`r�
� rl_ � ROUGH PLUMBING
LIC. N0: \�`'
GAS PIPING
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES i
xA �/
//i/ LAWN SPRINKLERS
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GAS TEST
UTILITY COMPANY NOTIFIED
CWV
GRAY WATER SYSTEM
REPORT ID: DPR263 ROUTE TO: BS0508