HomeMy Public PortalAbout5758 GOLDEN WEST AVE_Plumbing__ b -
WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
76A666 DPW 4/87
•�saherebafflrm that I have a certificate of consent to self in- 76A667A
sure,or a ce'rtificate of Workers'Compensation Insurance,oro 'CE 817(REV. 8/86)
certified'copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Polio No. Company
D ,Certified copy is hereby furnished.
FOR APPLICANT TO FILL INPRINT OR TYPE BUILDING
Certified copy is filed with th-e county building inspection ( ) ADDRESS ? O)
department. NUMBER FIXTURE OR ITEM Lal FEE
+rye LOCALITY
! WATER CLOSET(TOILET) (/
Date Applicant NEAREST fes, �
CERTIFICATE OF,EXEMPTION FROM WORKERS' 'BATH TUB CROSS ST. !fir
COMPENSATION INSURANCE SHOWERN OWNER t cti, s
(This section need not be completed if the work involved by MAIL _ ` ,fir�n
the permit is for.one hundred dollars ($100)or less.) LAVATORY ADDRESS GQ d QV �'o� v}f Y,
I certify that in'the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY (1 TEL. NO. O
as to become subject to the Workers'Compensation La DISI-IWASHER
nn CONTRACTOR
Date Applicant w� CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making thi ertificote of Ex- SWIMMING POOL RECEPTOR
emption, you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- ' STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. el�OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS /y /�_/ 1
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER (> d� �C�t
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect. DATE ,off
CL
License Number Lic. Class V +� U
FINAL cc
Contractor Date BY O
U
I am exempt under Sec.
B.BP:'C. for this reason Plan check fee oil.PLUMBING PERMIT ISSUING FEE $ �—
Signature
TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason '(Section 7031.5, Business and
Professions Code): - Address
:3t_F i'
as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044; s i=E fI L 43 = 00
Business and Professions Code). oil.CONSTRUCTION LENDING AGENCY •HECK. 43.01 OF "
I hereby affirm that there is a construction lending agency for CHANGE i%-(
the performance of the work-for which this permit is issued
(Sec. 3097, Civ. C.).
•t ;
Lender's Name
7C H0
Lender's Address
I certify that I have read this application and state that the 1011111'.above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of, is County to enter upon the
above-m�tioned pr perty nspec 'on purposes.
s /`7/ , � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date ,
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING RMIT-)
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS PL-0508-9PE706180002
BUILDING AND -SAFETY / LAND DEVELOPMENT- TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL ID• FEES PAID BUILDI G_ADDRESS:_- �
TR: 6561 LT: 454 05758 GOLDEN-WEST-AV--
TION:
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP-CA 917802503
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
8587-028-013 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3- LOCALITY: TEMPLE CITY
07 BATHTUBS/SHOWERS 3.00 FIX 49.05
TENANT: 11 CLOTHESWASHER(S) 1.00 FIX 16.35 ISSUED ON: PROCESSED B PLAN BY: EXPIRES ON:
13 DISHWASHERS) 1.00 FIX 16.35 06/23/97 TC 06/23/98
21 HOSE BIBB(S) 4.00 FIX 65.40
OWNER: TEL. NO: 25 LAVATORIES/SINKS 6.00 FIX 98.10 FINAL DATE , FINAL CODE:
RICHARDS STEPHEN B;CORRIE J (818).500 6728- 45 WATER CLOSET/URINAL 3.00 FIX 49.05 '1,348
5758 GOLDEN WEST AV 47 WATER HEATER(S) 1.00 WTH 16.35
TEMP 917802503 51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.35 DESCRIPTION OF WORK
52 ADDN OUTLETS .> 5 4.00 OUT. 16.80 PLUMBING FOR.NEW ADDITION AND.INTERIOR REMODELING
TOTAL FEES 371.55
APPLICANT: TEL. N0:
FRANK MARRONE AND SONS, INC. (818) 444-2548-
SPECIAL CONDITIONS:
CONTRACTOR: TEL. N0: APPROVALS DATE INSPECTOR SIGNATURE
FRANK MARRONE AND SONS, INC. (818) 444-2548
ND R SLAB WORK
9860 LOWER AZUSA ROAD LIC. NO
EL MONTE, CA 91731 016/
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: TEL. N0: /
(818) 564-2650-THE WREN GROUP ` ROUGH PLUMBING
44 W. BELLUVUE DRIVE LIC. NO:
SUITE 6 C21565 GAS PIPING
PASADENA, CA 91105
HOT WATER HEATER
PLUMBING FIXTURES
G S TEST
i/j C C FJ/jIM. L
AV UTILITY COP Y .NOTIFIED
CWV
GRAY WATER SYSTEM
* ADDITIONAL DATA ON FILE
REPORT ID: DPR263 ROUTE TO: BS0508