The URL can be used to link to this page

Home My Public Portal About5838 GOLDEN WEST AVE_Plumbing__ 'WORKERS' COMPENSATION DECLARATION20-0026 1 'APPLICATION FOR PLUMBING PERMIT J,_4('re of?,i�m that I have a•certificate of consent to self in- 76A667A PW 4/S7 26r`o or a certificotq,of Workers'C6mpensation Insurance,or-a CE 817(REV. 8/86) - certified-copy thereof (Sec. 3800, Lab. C.) Policy Ng "' Company COUNTY OF LOS ANGELES DEPT. OF.PUBLIC WORKS F Certified copy is hereby furnished' y FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ll ¢ QCertified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE h LOCALITY Date Applicant. WATER CLOSET(TOILET) V NEAREST L - dJf CROSS ST. fS n/As.. ' • CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB �• COMPENSATION INSURANCE • "I SHOWER ,✓,., D OWNER- ti//�L (This section need not be completed if the work involved by v MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ] ADDRESS S. �� I certify that-in the performance of the orl�for which this per- CITY TEL. NO. mit'is'issued, I shall not employ any erso/n in any man.erso SINK',/ fi r I�Z,Pg&�4; as to betime subject"to the Worker 'Co pens io ws. DISHWASHER /cCONTRACTORDate Applicnn i CLOTHES WASHER NOTICE fO APPLICANT: If, after making this"Certificate of,Ex- ADDRESS 5��4 emption, you should become subject to the Workers'Comp - I SWIMMING POOL RECEPTOR CITY TEL. NO. sation provisions of the Labor Code, you must forthwith co p- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revo STATE LIC ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION . DISTRiCZNO.\ PRO &SED B.Y .I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER (f a and Professions Code; and my license is in full force'and ef- 5 PER SYSTEM FINAL VALID TION fect. DATE O License Number Lic. Class, h 1� FINAL ,� Contractor Date BY !f i6 O I am exempt under Sec. B.&P.C. for this reason W g Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ _ 2 0.3 9.7'A e Signature' #,0-0,0,0 5 5 TOTAL FEE L SINGLE FAMILY � o 0 HOME OWNER-BUILDER DECLARATION Plan check applicant 1 5 a 0 I hereby affirm that I am exempt from the Contractor's License Name o o,0 5 a 5 0 v Law for the following reason (Section 7031.5, Business and ' Professions Code): Address 08. 1 8 ( 0, 8 8 DI—as owner of the property,"will do the work and the City Tel. No. 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 tify cerI have read this application and state that the _ abov nform�tion is correct. I agree to comply with all County , ordi antes a d State laws gulating Plumbing, and hereby aut orize reresenta ives of this County to enter upon the ab ve-men toned I p y for inspectn purposes. 1Q SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Per mitte D to WORKERS'COMPLJSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of conserit to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certifi copy thereoof�Sec. 3800, b. 'C COUNTY OF LOS ANGELES T'e . BUILDING AND SAFETY Policy N 70 C-bmpony ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS tincl artment. NUMBER FIXTURE OR ITEM @ FEE LOCALITY /(� Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER SHOWER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITEL. N0. so as to become subject to the Workers Compensation Laws. DISHWASHER CONTRACTORao 114 Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of {^ Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY TEL. NO LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICTWO. SEMY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �`o r� (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and m license is in full force and effect. 5 PER SYSTEM Y FINALVALIDATION L --20 DATE ��& � License Number Lic. Classa r J_ e—, P- 1FINA tN Contracts, 6<, �PS�M,�Date� — BY a ❑ I am exempt under Sec. B.&P.C. for this reason Date: Plan check fee ® g PLUMBING PERMIT ISSUING FEE$ /Q ,SOS Signature TOTAL FEE • o i-,D 2325 Plan check applicant SINGLE FAMILY n o o o r7 HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address �` o Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. ` " 7 0. 15 G= ❑ I, as owner of the property, will do the work and the - 0 - 2 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 representatives of this County to enter upon the above-mentioned propert r for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE i 6,9ture of Permittee Date i t COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0106220009 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: TR: 6561 LT: 446 5838 GOLDEN WEST AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802203 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LAS TUNAS DRIVE 8587-027-019 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY 51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20 TENANT: TOTAL FEES 43.95 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 06/22/01 JK 12/19/01 OWNER: TEL. NO: FINAL D TE L CODE: RUCKLE, TERRY (626) 285-7370- 5838 GOLDEN WEST (p �� TEMP 917802203 D GAS LINE SCINNEE FFOI0 WOR OR BBQ APPLICANT: TEL. NO: CALIFORNIA POOLS (626) 285-2261- 8806 LAS TRUNAS DR. SPECIAL CONDITIONS: TEMPLE CITY CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE CALIFORNIA POOLS (626) 285-2261- 8806 85-2261 8806 E. LAS TUNAS DRIVE LIC. NO UNDER SLAB WORK SAN GABRIEL CA 185102C53 WATER SERVICE PLASTIC Y/N METAL Y/N ARCHITECT OR ENGINEER: TEL. NO: ROUGH PLUMBING LIC. N0: I � - - � GAS PIPING GAS VENT I HOT WATER HEATER i PLUMBING FIXTURES LAWN SPRINKLERS !!!� GAS TEST UTILITY COMPANY NOTIFIED CWV GRAY WATER SYSTEM REPORT ID: DPR263 ROUTE TO: BS0508