HomeMy Public PortalAbout10817 FREER ST_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a certifie coP h eQfgSqtc. 38 )C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Cie- I
CC�
Policy No. ompanyu
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
❑' Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE.
e� LOCALITY
Date Applicant WATER CLOSET ,� pc NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB �� Z? CROSS ST.
COMPENSATION INSURANCE OWNER (J 1
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars $100 or less. MAIL
P ( ) � LAVATORY � � ADDRESS
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY ly
TEL. N . Z
so as to become subject to the Workers'Compensation Laws. DISHWASHERf
CONTRACTOR
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM �6
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. ' WATER HEATERLICENSE NO. CLASS
1_0
LICENSED CONTRACTORS DECLARATION DISTRICT U0, PROCES ZED BY
22
I hereby affirm that I am licensed under provisions of Chapter 9' GAS SYSTEM OUTLETS 10 D a
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM d FINALQ Z VALIDATION
DATE — -!
License Number Lic. Class ¢3,� 0.
/ FINAL
Contractor 9 � BY �
❑ 1 am exempt under Sec.
B.&P.C. for this reason Mut
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature 4� 4)
TOTAL FEE ��J
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License rfc•(•1 a a
Law for the following reason (Section 7031.5, Business and Address ^_
Professions Code): City Tel. No. ' ==`•i
❑ i1
I, as owner of the property, will do the work and the .L I lr.,,,a
structureis not intended or offered for sale (Section
7044, Business and Professions Code). E _ IEiL � � 00
CONSTRUCTION LENDING AGENCY CHECK
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued :i'IHNGE
(Sec. 3097, Civ. C.).
Lender's Name !i_I 10 E{lis j E ,_
Lender's Address
(Sabove-
at I hav read this application and state that the ► [E=° + fii a x ss
mation is correct. I gree to comply with all'County
and State laws r ulating Plumbing, and hereby
epresentatives f this County to enter upon the
tioned property f r inspe tion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Pe t Date (�
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1104200001
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: 1 FEES PAID 1 BUILDING ADDRESS: 1
ITR: 47219 LT: 1 UN: 6 I 1 10817 FREER ST I
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917803538 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: SANTA ANITA 1
18573-014-068 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: D4 LOCALITY: TEMPLE CITY, Cl
I 113 DISHWASHERS) 1.00 FIX 16.30 1 I
(TENANT: 125 LAVATORIES/SINKS 1.00 FIX 16.30 (ISSUED ON: PROCESSED BY: PLAN BY: 1
1 TOTAL FEES 60.40 104/20/11 SR 1
10WNER: TEL. NO: 1 IFINAL DATE FINAL BY: CODE: 1
ILIN, THOMAS - I t�k
I
110817 FREER ST I 1i 1
ITEMP 917803538 1 IDESCRI TION'OF WORK
I I 1REPLACE DISHWASHER, SINK FOR KITCHEN REMODEL
(APPLICANT: TEL. NO:
1168 CONSTRUCTION & REMODELING (626) 284-6682- 1 1
1821 S. 4TH ST. #17 1 ISPECIAL CONDITIONS:
1ALHAMBRA, CA 91801 I
I I I I
ICONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE 1
1168 CONSTRUCTION AND REMODELING (626) 284-6682- 1 1 I
1821 S. 4TH STREET #17 LIC. NO 1 (UNDER SLAB WORK I I
1ALHAMBRA, CA 91801 899733 B 1 I
IWATER SERVICE I
I IPLASTIC Y/N METAL Y/N I
(ARCHITECT OR ENGINEER: TEL. NO: 1 I I I
- IROUGH PLUMBING
LIC. NO: I
IGAS PIPING
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I IGAS VENT 1 I 1
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IHOT 6IATER HEATER I I I
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I (PLUMBING FIXTURES I I I
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I 1 1LAWN SPRINKLERS
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I IGAS TEST I
I1 11
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I (UTILITY COMPANY NOTIFIEDI I I
I ICWV I I
I I 1GRAY WATER SYSTEM
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I IREPORT ID: DPR263 ROUTE TO: BS0508
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