HomeMy Public PortalAbout5324 FRATUS DR_Plumbing__ i�2Y�� I �JOKCRS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
y,affirm thor+i have a certificate of consent to self 76A667A
insure, or d certificate of Workers' Compensation Insurance, CE 817 (REV 8/86)
ora certified copy thereof (Sec 3800, Lab C )
i (IS/4 • COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy Nd" Eompany�""'�'�� Z& `
❑ rtified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 31 �O �� S
Certified copy is filed with the county building mspec_ ADDRESS J /`
tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY t�
Date l-3 A li ante" r �' WATER CLOSET 1:2— ) rG� f
/ ��pp S — .o---- NEAREST /!
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB Q CROSS ST �� V G
COMPENSATION INSURANCE 1 /1 OWNER Lp 1,4 l� >►�h
(This section need not be completed,if the work involved by SHOWER I V
MAIL I
the permit is for one hundred dollars($100)or less ) LAVATORY /011- 60 DDRESS
I certify that in the performance of the work for which this c/
permit is issued, I shall not employ any person in any manner SINK CITY T45 v1I £ G� r TEL N0 .b G� h�
so as to become subject to the Workers'Compensation Laws DISHWASHER
CONTRACTOR 6�Av•rr- L , ,F,
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT If, after making this Certificate of ADDRESS � �'-� her O 11-10-R/
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY �Q 11 , QA O '� TEL NO
with comply with such provisions or this permit shall be STATES //�� D LIC
deemed revoked If WATER HEATER LICENSE NO -f CLASS
} LICENSED CONTRACTORS DECLARATION . DISTRICT NO ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER V v ij
and Professions Code,and my license is in full force and effect 5 PER SYSTEM
mb�++Fwt� P3/—�7 FINAL
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License Number Lic Class IxO
Contractor " Z// ate
U
❑ I am exempt under Sec
B 8P C for this reason , Z
Plan check fee
Date PLUMBING PERMIT ISSUING FEE$
Signature '
TOTAL FEE
Plan check applicant T
SINGLE FAMILY � ;2 7 5 7.6 A
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License # o 0 0 0 0 5
Law for the following reason (Section 7031 5, Business and Address
Professions Code) City Tel No
I,o -765'0
❑ 1, as owner of the property, will do the work and the ° ° ° 6 5 0 5
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 repres totives of this County to enter upon the
above-mention operty for inspection purposes
' SEE REVERSE FOR EXPLANATORY LANGUAGE
-7-3 �7 r
ignature Nfer Mee Date
• COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1311140033
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
LEGAL ID FEES PAID I BUILDING ADDRESS
ITR 11492 LT 20 BL B I 5324 FRATUS DR
1 _IFEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917803118
ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET OLIVE
18590-002-022 101 PERMIT ISSUANCE FEE 27 80 THOMAS PAGE 596 GRID J4 LOCALITY TEMPLE CITY CAI
I 113 DISHWASHER(S) 1 00 FIX 16 20
TENANT 125 LAVATORIES/SINKS 3 00 FIX 48 60 JISSUED ON PROCESSED BY PLAN BY
I 147 WATER HEATER(S) 1 00 WTH 16 20 11/14/13 SR I
I 1 TOTAL FEES 108 80 I
OWNER TEL NO I IF NAL FINAL B CODE
ILAM BRANDON L,CYNTHIA T -
15324 FRATUS DR el,p
1TEMP 917803118 IDE CRI TION bF WORK i1
I 1REPLACE DISHWASHER, TWO LAVATORIES, SINK AND WATER HEATER
I
(APPLICANT TEL NO I
1SAME AS OWNER
ISPECIAL CONDITIONS
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ICONTRACTOR TEL NO 1 (APPROVALS DATE INSPECTOR SIGNATURE I
ISAME AS OWNER - 1 I-
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LIC NO JUNDER SLAB WORK I I I
I 1 1WATER SERVICE
I I 1PLASTIC YIN METAL YIN 1 I I
(ARCHITECT OR ENGINEER TEL NO I 1 1 1 1
1 - I IROUGH PLUMBING
1 I 1
LIC NO I
1 I I 1
IGAS PIPING 1
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IGAS VENT I 1
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I 1 1HOT WATER HEATER I I 1
I 1 1PLUMBING FIXTURES
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ILAWN SPRINKLERS 1 I I
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I IGAS TEST 1 1 I
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1 I IUTIi,ITY COMPANY NOTIFIEDI I 1
I IcWV 1 I I
IGRAY WATER SYSTEM
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1 IPEPORT ID DPR263 ROUTE TO BS0508 1 1 I I
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