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Home My Public Portal About6209-6211 GOLDEN WEST AVE_Plumbing__ 3 _ —r ,cf_ �� WORKERS COMPENSATION DECLARATION A®®LICA I®N C R PLUMBING PERMITIT L�'ci'tbQ a firm that I have a certificate of consent to self 76A667A u ins�rep of a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OFICIS ANGELES .. _._._ BUILDING AND SAFETY . Policy No. Company ❑ Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE)❑ ADDRESS Certified copy is filed with the county building inspec- tion .- •- - tion department. NUMBER FIXTURE OR ITEM @ FEE' LOCALITY Date Applicant WATER.CLOSET _ - NEAREST* CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. oq COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. so as to become subject to the Workers Compensation Laws. DISHWASHER 't /� CONTRACTO �^ VIP.-19e "Applicant CLOTHES WASHER ADDRESS, NOTICE TO APPLICANT: If, after m ing this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE- -�/ LIC. � deemed revoked. WATER HEATER LICENSE NO. Z CLASS Z LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 15 PER SYSTEM FINAL - . VALIDATIO /J�✓ DATE License ° License Numbaa`�r"�� Lic. Clas n FINAL- U. 246pl�:� A"77 Datl_ `—"5 6 BY I am exempt under Sec. _ _ .. __ • O B.&P.C. for this reason V Plan check fee Date: ® •.. . . .__.. ., Z PLUMBING PERMIT ISSUING FEE$ Signature m- TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, By and Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the ;2 5 6 a 4 A structure is not intended or offered for sale (Section ® # 0 0 0 0.0 5 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY Ioa1650 I hereby affirm that there is a construction lending agency for o 0 0 16506 the performance of the work for which this permit is issued (Sec. 3097,.Civ. C.). - _ _ _ I Q 14 `8 6 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-m ntioned property for inspection purposes. •- SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date APPLICATION FOR PLUMBING PERMIT WOFKERS COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) u or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NoU�86237987ompany Fremont lJ Certified copy is hereby furnished. ® FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ow Certified copy is filed with the county building inspec- ADDRESS Golden West tion department. NUMBER FIXTURE OR ITEM FEE LOCALITY '� r Date-15-86 Applicant 0470n Rrnc P1 bg d. WATER CLOSET NEAREST Tem le City CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BATH TUB M _ CROSS ST. COMPENSATION INSURANCE 2 SHOWER OWNER Chila Construction (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) 4 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 2 SINK _ CITY Arcadia TEL. NO. 446-1128 so as to become subject to the Workers'Compensation Laws. DISHWASHER 2 CONTRACTOR Olden $Y'OS. Plumbing Inc. Date Applicant 2 CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of 4265 N. Baldwin Ave. Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- El Monte 443-0078 LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. 2 WATER HEATER _ LICENSE NO. 231 741 CLASS C36-20 LICENSED CONTRACTORS DECLARATION DISTRICT NO. ESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 2 GAS SYSTEM OUTLETS V/► (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and effect. 5 PER SYSTEM __ FINAL bAll TION 0�. License Number 231 741 Lic. Class C36-20 0 FINAL Q. ContractorOWen BrQS. Plbcr.Date 5-15-86 BY 0: ❑ I O am exempt under Sec. � U B.BP.C. for this reason W Plan check fee ® N Date: PLUMBING PERMIT ISSUING FEE$ Signature p4 b 8 0 A TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name # o 0 0 0 0 5 I hereby affirm that I am exempt from the Contractor's License ) a 1 48,50 Law for the following reason (Section 7031.5, Business and Address o 0 1 4 8 5 0 v Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the o5,2 1 -8b 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 eobe-men e representatives of t ounty to enter upon the 'pd ffropeJ1rs ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 5-15-86 S nature of Permitte Date COUNTY OF LOS ANGELES TEMPLE CITY - # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0608180016 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: ON FILE 6211 GOLDEN WEST AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 91780 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LONDGEN 5385-020-004 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY, C 47 WATER HEATER(S) 1.00 WTH 16.20 TENANT: TOTAL FEES 43.95 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 08/18/06 JK 02/14/07 OWNER: TEL. NO: FINA TE FINAL BY: CODE: SUMIDA, VICKIE/HARUTO (626) 286-1732- 0 6211 GOLDEN WEST AV TEMP 917801705 DESCIXIPTIdN OF WORK WATO HEATER CHANGE OUT APPLICANT: TEL. NO: TEKAWA (310) 515-1311- 17111 S. BROADWAY SPECIAL CONDITIONS: GARDENA, CA 90248 CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE. ACTION CONTRACTORS (310) 515-1311- 17111 SOUTH BROADWAY LIC. NO UNDER SLAB WORK GARDENA, CA 90248 B/L00000 WATER SERVICE PLASTIC YIN METAL YIN ARCHITECT OR ENGINEER: TEL. NO: - - ROUGH PLUMBING LIC. N0: GAS PIPING GAS VENT HOT WATER HEATER PLUMBING FIXTURES LAWIT SPRINKLERS GAS TEST UTILITY COMPANY NOTIFIED CWV GRAY WATER SYSTEM * ADDITIONAL DATA ON FILE REPORT ID: DPR263 ROUTE TO: BS0508 COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0802260004 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: ON FILE 6209 GOLDEN WEST AV 1FEE DESCRIPTION: QUANTITY: DOM: AMOUNT: 1 TEMP CA 91780 ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: 15385-020-004 101 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY, Cl 1 147 WATER HEATER(S) 1.00 WTH 16.20 I 1 (TENANT: 1 TOTAL FEES 43.95 JISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 1 1 102/26/08 SR 08/24/08 1 I 1 I 1OWNER: TEL. NO: FINAL DATFIN CODE: 1SUMIDA, VICKIE & HARUTO IPO BOX 1486 1TEMPLE CITY CA 91780 JDVSCRIPTION OF WORK I 1REMOVE/REPLACE GAS WATER HEATER I 1APPLICANT: TEL. NO: I I (FAST WATER HEATER COMPANY (425) 814-9516- 1 1 1 112601 132ND. AVE. I 1SPECIAL CONDITIONS: 1 1KIRKLAND, WA 98034 I I I I I I I I 1CONTRACTOR: TEL. NO: I 1APPROVALS DATE INSPECTOR SIGNATURE 1 1FAST WATER HEATER CO. (425) 814-9516- 1 1 1 112601 132 AVE. NE LIC. NO 1 1UNDER SLAB WORK I I I 1KIRKLAND WA 98034 877489 C36 1 1-1 1 1 1 (WATER SERVICE 1 1 1PLASTIC Y/N METAL Y/N 1 1 1 1ARCHITECT OR ENGINEER: TEL. NO: 1 I 1 I I 1ROUGH PLUMBING 1 1 1 LIC. NO: 1 1 1 1 1 1 1 IGAS PIPING 1 1 I I I I I I 1 1 IGAS VENT I I I 1 I IHOT WATER HEATER ( / f I 1 1PLUMBING FIXTURES 1 1 1 1LAWN SPRINKLERS I i I I I I I I 1 IGAS TEST I 1 1 I 1 I I 1 I 1UTILITY COMPANY NOTIFIEDI I I I I I I I I I I ICWV I I I I I I I I (GRAY WATER SYSTEM I I I I I I I I I I I I I I I I I i I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I 1REPORT ID: DPR263 ROUTE TO: BSO508 1 1 1 1 I I I I I I