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HomeMy Public PortalAbout6241 GOLDEN WEST AVE_Plumbing__ WOR ERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �I heFeLS 'affirm that I have a certificate of consent to self 76A667A insures, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or�a�^certiff�: cop there f (Se 3800, Lab. C.)�t COUNTY OF LOS ANGELES BUILDING AND SAFETY tl� olicy 1`70. © �— ® .`�S nY ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING� GO�I ,' Certified copy is filed with the county building inspec- ADDRESS �tL tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date _V Applicant WATER CLOSET 600 o© NEAREST ��pP��G BATH TUB CROSS ST. d(sAl(p . CERTIFICATE OF EXEMPTIO FROM WORKERS' I Q('� COMPENSATION I SURANCESHOWER OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) 3i LAVATORY pD ADDRESS 8�_ Slid y1C1jW11r__ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK I 00 CITY TEL. NO.J% f3 so as to become subject to the Workers Compensation Laws. DISHWASHERCONTRACTOR�O Y/ w lL� -� QD „r Ate Date Applicant j CLOTHES WASHER ADDRESS 0.] NOTICE TO APPLICANT: If, after making this Certificate of61,40060,D it Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR ' CITY '/ TEL. NO. Compensation provisions of the Labor Code, you must forth- G(� `/® o LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall bep STATE LIC. deemed revoked. 8 WATER HEATER o LICENSE NO. Q® CLASS C-5� LICENSED CONTRACTORS DECLARATION DISTRICT NO7� ROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS to ® (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �J f/ and Professions Code, and my license is in full force �and s�effect. 5 PER SYSTEM DATE EL�� V (DATION License Number 37000 Lic. Class�,l` FINAL Contractor Date BY t= Iam empt under Sec. B.& .C. for this reason Date: z 3 8 9. 8 A g Plan check fee ® � m PLUMBING PERMIT ISSUING FEE$ O Signature # 0 0 0 0 0 5 TOTAL FEE Plan check applicant Ioa8250 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name o - 82-5060 . I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address 1.2 2—8 6 Professions Code): 1 City Tel. No. ❑ I, as owner of the property, will do the work and the 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si ture of ermittee Date COUNTY OF LOS ANGELES• TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0902110012 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: ON FILE 6241 GOLDEN WEST AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA 917801705 ASSESSOR INFORMATION NUMBER: 1 - I NEAREST CROSS STREET: 15385-021-012 101 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY, C1 1 107 BATHTUBS/SHOWERS 2.00 FIX 32.40 (TENANT: I11 CLOTHESWASHER(S) 1.00 FIX 16.20 (ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 113 DISHWASHER(S) 1.00 FIX 16.20 102/11/09 SR 08/10/09 121 HOSE BIBB(S) 2.00 FIX 32.40 OWNER: TEL. NO: 125 LAVATORIES/SINKS 3.00 FIX 48.60 1F NAL DATE FIN BY: CODE: 1CHEN, CHIN (626) 235-2233- 145 WATER CLOSET/URINAL 3.00 FIX 48.60 1 ¢} 16241 GOLDEN WEST AV 147 WATER HEATER(S) 1.00 WTH 16.20y/V TEMP 917801705 149 WATER TREATING EQUIP 1.00 SYS 16.20 iDtSCRIPTIONIOF WORK TOTAL FEES 254.55 IPLUMBING FOR KITCHEN AND BATHROOMS REMODEL (APPLICANT: TEL. NO: 1LIM (213) 210-3979- 17250 BANDINI BLVD. ISPECIAL CONDITIONS: 1 1LOS ANGELES CA 90040 1 I I CONTRACTOR: TEL. NO: JAPPROVALS DATE INSPECTOR SIGNATURE SOUTHERN CALIFORNIA CONSTRUCTION (714) 220-7460- 18611 E. ROLAND ST. LIC. NO JUNDER SLAB WORK 1BUENA PARK, CA 90621 862693 B 1 1 WATER SERVICE PLASTIC Y/N METAL Y/N (ARCHITECT OR ENGINEER: TEL. NO: I 1J C ENGINEERING (213) 210-3979- 1 1ROUGH PLUMBING L��� 12155 VERDUGO BLVD #124 LIC. NO: � � IMONTROSE, CA 91020 40597 I GAS PIPING GAS VENT � � I 1HOT WATER HEATER I I � 1PLUMBING FIXTURES � � I LAWN SPRINKLERS � � I 1GAS TEST I I � UTILITY COMPANY NOTIFIED ICWV 1GRAY WATER SYSTEM 1 1 I I I I 1REPORT ID: DPR263 ROUTE TO: BS0508 I