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Home My Public Portal About6013 GOLDEN WEST AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATI®N FOR PLUMBING PERMIT I hereby afil'rm that I have a certifiicate of cionsent to self 20-0026 DPW 6/87 ♦� insure, or a certificate of Workers' Compensation Insurance, 76A667A or a certified copy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. BUILDING / ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS tion department. Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM Q FEE LOCALITY o Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. Q (f COMPENSATION INSURANCE ` SHOWER OWNER (This section need not be completed If the work Involved by MAIL the permit Is for one hundred dollars ($100)or less.) LAVATORY ADDRESS 1 certify that in the performance of the work for which this permit is issued, I shall not employ.ony person in any manner SINK CITY TEL. NO.,g lam? so as to becom subject to the Wo Compe tion Laws. v> e?_ J. DISHWASHER CONTRACTOR Date J ! Applican A CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certifi ate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO ROLES BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS G�' ® (� (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �"J U and Professions Code,and m license is in full force and effect. 5 PER SYSTEM Y FINAL LIDATION 0.1 DATE 0. License Number Lic. Class 0. FINAL � f Contractor _Date BY O ❑ I am exempt under Sec. / U I/ 6td B.&P.C. for this reason Plan check fee Z Date: PLUMBING PERMIT ISSUING FEE$ b 0 Signature TOTAL FEE SINGLE FAMILY Plan check applicant _ HOME OWNER-BUILDER DECLARATION Name _ I hereby affirm that I am exempt from the Contractor's License t��•(•) o s Law for the following reason (Section 7031.5, Business and Address Professions Code): City Tel. No. "^`I)' ❑ 1, as owner of the property, will do the work and the 1 I;'EMS structure is not intended or offered for sale (Section 7044, Business and Professions Code). Poo ENTAL 20 - 50 CONSTRUCTION LENDING AGENCY t;H (•}� 20.50 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CHANGE „00 (Sec. 3097, Civ. C.). Lender's Name 00100-900 1 5f 1/90 Lender's Address I certify that I have read this application and state that the ® C1•+1-64 1 AN10"c-t' above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize representati of this County to enter upon the ov -mentioned pro ert for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE mature of PE bate WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby _,pffirm that I have a certificate of consent to self 20-0026 DPW 6/87 T insure;or a certificate of Workers' Compensation Insurance, 76A667A o#d certified copy thereof (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. • Company Certified copy is hereby furnished. BUILDING I ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Q/ QLjJE�p LL� c' E Certified copy is filed with the county building inspec- tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Appligant t WATER CLOSET NEAREST Lr CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB gACUZZCROSS SL 1,0 00D RU r COMPENSATION INSURANCE SHOWER OWNER U o +�Egg RP I (This section need not be completed If the work Involved by MAIL the permit Is for one hundred dollars ($100)or loss.) LAVATORY ' ADDRESS ¢ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in�nLaws. SINK CITY TEL i . so as to become subject to the W s'Compe at! DISHWASHER C CONTRACTOR Date - Applica CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of A�E Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR p y I CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO.,WCi (� CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business ' OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION 0.1 DATE/,-' 0, License Number Lic. Class 5 FINA, cvl. Contractor Date BY 1 am exempt under Sec. B.6P.C. for this reason Plan check fee N Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant SINGLE FAMILY .j' - _.. .._. HOME OWNER-BUILDER DECLARATION Name rru4WI ni? I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and d�a•d1r Professions Code): City Tel. No. 3M7 T ❑ I, as owner of the property, will do the work and the I EM structure is not intended or offered for sale (Section ® TOTS,. a- 9®50 7044, Business and Professions Code). ac� yy CONSTRUCTION LENDING AGENCY ��' 28 3YJ I hereby affirm that there is a construction lending agency for I the performance of the work for which this permit is issued ° (Sec. 3097, Civ. C.). Lender's Name 113MCKMI 9/ 6/89 Lender's Address 5.522 1 IN 9914 1 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 bole-mention operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ature of Permittee F Dat COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0302250049 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDINGADDRESS: TR: 6561 LT: 94 6013 GOLDEN WEST AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801719 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: WOODRUFF 5385-019-010 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A2 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: 02/25/03 JK 08/24/03 OWNER: TEL. NO: FINAL DATE FINAL BY: CODE: SAPIA DANNY K;TERESA L (626) 287-1032- 6013 GOLDEN WEST AV TEMP 917801719 DESCRIPTION OF WORK GASLINE FOR HEATER APPLICANT: TEL. NO: SAME AS OWNER SPECIAL CONDITIONS: CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE SAME AS OWNER LIC. NO UNDER SLAB WORK WATER SERVICE PLASTIC Y/N METAL Y/N ARCHITECT OR ENGINEER: TEL. NO: ROUGH PLUMBING LIC. NO: GAS PIPING GAS VENT HOT WATER HEATER PLUMBING FIXTURES LAWN SPRINKLERS GAS TEST UTILITY COMPANY NOTIFIED CWV GRAY WATER SYSTEM REPORT ID: DPR263 ROUTE TO: BS0508