HomeMy Public PortalAbout10749 FREER ST_Plumbing__ • 'WORKERS' COMPENSATION DECLARATION APPLICATION FOR' PLUMBING' PERMIT -'
:I hereby;affirm that I have a'certificate of consent to self in- 76A667A-0026 PW a/87
sure,or a certificate of Workers'Compensation Insurance,ora CE'817(REV 8/86) `I I
certified copy,thereof (Sec 3800,lab C.),; LJ
Policy No''G�I9[o-�j'Company S ► vn� 4 COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy'is hereby furnished ,
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
�ertified copy is filed with the-courity building'mspectionADDRESS
department NUMBER ` FIXTUREORITEM @. FEE' LOCALITY'
,b-1='P°1=. ' A h�p�t (�i,nJ r ' 6 2 WATER CLOSET(TOILET),
Date pp PIJ rn lh r JlCi. NEAREST
" ,CERTIFICATE OF"EXEMPTION FROM WORKERS' BATH TUB CROSS ST 113
tf
COMPENSATION INSURANCE•' SHOWER OWNER ; t
(This'section•need not' a completed if the work-involved by
MAIL C
the permit-is for one hundred dollars ($100)or less.) LAVATORY ADDRESS �yV1
' certify that-in the performance of the work for which this per-
mitis issued„1 shall not'employpny person in any manner so SINK t' CITY TEL NO
as to,become,sub'lecf to-the,•Workers' Compensation Laws - DISHWASHER -
j -CONTRACTOR' �O1L�S. IOt
Date ”' r, a "Applicant• CLOTHES WASHER, 1
NOTI(fE'TO_APPLlt4NT.1'fi after making this Certificate of.Ex- ADDRESS S. �A1 �
em tion, ou should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR
P Y I P CITY•,. TEL NO;4 O
sahon provisioris:of.the Cabo?Code;.you must forthwith comp- ,, :LAWN•SPRINKLER SYSTEM a '• -
ly:with such'proyiswns-or'this ermrt shaIl.6e,deemed-revak-'. STATE- _ LL LIC
.-,ed. :'. WATER HEATER LICENSE NO SO S 7. CLASS
:.LICE NSED,CONTRAGTORS DECLARATION " ' DISTRICT PR ES ED BY.,
I hereby affirm that I am'licensed under provisions-of Chapter GAS SYSTEM OUTLETS _
9(commencing with Sechon•7000)of Division 3 of the Business OUTLETS OVER.
`and Professions Code,`and my license is'in fu.114orce and ef- 5 PER SYSTEM
tett FINAL - VALIDATION a
.. DATE
License Number`S 6` 1`4k1 Lit Class
+� °lam FIN U
Corilydctor,�Je f{tlOr�)nef '�l:,Date •c�eS'^9 B 0
O
16m exempt under Sec. W
• y: - .._ N
4
•'B.BP C''for this reason "
• Plan check fee • - -' ® rn
Date-
PLUMBING PERMIT ISSUING FEE
Signature• % TOTAL FEE
T , SINGLE FAMILY. '''
HOME OWNER-BUILDER DECLARATION Plan check apphcarit
I hereby affirm that I am'exempt from the Contractor's'LicenseName
Law for the following reason (Section,7031 5,-Business and a
Professions Code):. Address ACCT.
I; as owner of theCit Tel No
71
33
property, will do the work and the Y `» �� 1�es
m
structure is not in (tended or offered for sale Section 7044,; - :•
Business and Professions Code) I. ITEMS
TOTAL 16 5y1F
CONSTRUCTION LENDING AGENCY' • = ° ;
I hefeby affirm that there,is a construction lendirig,agency for' CHECK
the,performance.of-the work for which This permit is issued .
( Gv, C ) 4'
CHANGE
Sec•'3097, e00
nder;'s-Name
Le
, . - 0000-0001 ' 6/28/39
'Cender s Address. ry; i'•�,..
I certft.that I have read this applicatiori-and state that the
4229 1 AM 10:41
above mformation'is correct, I agree to comply'with all County
ordind"ces and State laws regulating Plumbirig; and hereby
authoriseauthorise representatives of this County to enter upon-the
above-mentioned prop for,ins ecIion�purposes.
SEE-REVERSE,FOR EXPLANATORY LANGUAGE i
gnature of Permute ate '
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT-OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 04062/0019
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 DUPLICATE
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAIDBUILDING ADDRESS:
TR: 13613 LT: 30 I_ ' 10749 FREER ST
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( TEMP CA 917803533
ASSESSCR INFORMATION NUMBER: I NEAREST CROSS STREET: EL MONTE AVE.
8573-005-018 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: _597 .. GRID: C4 LOCALITY: TEMPLE CITY, C
07 BATHTUBS/SHOWERS 1.00 FJX = •16.20
TENANT: 25 LAVATORIES/SINKS 1.00 FIX 16.20 ISSUED ON: PROCESSED BY: PLAN BY: EXPIR S ON:
45 WATER CLOSET/URINAL 1.00 FIX 16.20 06/21/04 JK 12/18/04
51 LOW PRS GAS 5 OUTLET i.00 SYS 16.20
OWNER: TEL. NO: TOTAL FEES 92.55 FINAL ATE FINAL-3y. CODE:
LUONG/FLING, CHARLES/VIKKY (626) 279-7585- p
10749 FREER ST
TEMP 917803533 �)ES.RIPTION OF WORK
IPLOMBING FOR NEW BATHROOM
APPLICANT: TEL. NO:
HOANG (626) 673-6996 _
(SPECIAL CONDITIONS: �
CONTRACTOR: TEL. NO: iAPPROVALS DATE INSPECTOR SIGNATURE
LUONG/FUNG, CHARLES/VIKKY (626) 272-9248
10749 FREER ST. - LIC. NO' I UNDER. S6A& WOR
TEMPLE, CITY, CA 91780 NONE
WATER SERVICE
(PLASTIC Y/N METAL Y/N' I 1
ARCHITECT OR ENGINEER: TEL. NO: _I
HOANG, KEVIN (626) 673-6996- IRSUGH PLUtIGING
1820 S. CORDOVA ST. LIC. NO: I I_ OjIIY
nLuAMBR! , CA 91801 NONE -
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� (HOT WATER HEATER
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IPLUMBING FIXIUR S
LAWN SPRINKLERS
SPRINKLERS I !
GAS TEST
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lUTILiTY COMPANY NOTIFIED
CWV I-
3 ?GRAY WATER SYSTEM 1
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REPORT ID: DPR263 ROUTE TO: SS0508 I —