HomeMy Public PortalAbout6421 GOLDEN WEST AVE_Plumbing__ WORk]�RS'COMPENSATION DECLARATION 79Aa97A
I hereby af" that A have i certificate of consent to self ci 617 (2-80j APPLICATION FOR PLUMBING PERMIT.
Insure, or a certificate a Workers'Compensation Insurance,or
a certlf7ed copy thereof(Nc.3800,Lab.G.) COUNTY OF LOS ANGELES. BUI LDFNO AND SAFETY
Policy No. Company
Certified copy Is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
Certi}ied SPY is filed with the coynty bulldthg Inspection NUMBER FIXTURE OR tTtDM • FEE ADDRESS f� C14,�%CtM
LQCALITY
W AT E R CLOSET
-iT.*•
Datfi�,ApplicantEAREST
�i
CERTIFICATE OF EXEMPTION FROM WORKFRS BATH TUB CROSS$T-
COMPENSATION INSURA.NCF,
T_COMPENSATIONINSURANCF, SHOWER �OWNFR
IL
(Tlb wed" end Dot be
one hundred ONVk%tt�dOIf the
work oar LAVATORY MPDRESS
by the pCffiIt •
SINK CI TEL. NO
I certify thst In the performance of the work for,which this DISHWASHER
permit it issued, i shall not employ any person in any,manner CgNTRA
so as to become subject to the Worker"' Compen"tion Laws. CLOTHf_S WASHER ADDRESS
Dater Applicant SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT: If,after making,this Certificate of CITYTEL. N ,.
Exemption, you sb0uld become subject to the Workers' LAWN SPRINKLERSYSTEM a
STATE LID. fll
Compbnsatlon provisions of thq Labor Code, you must forth- LICENSE N CLASS Z
with comply with such WATER FIEATSR _
p y provfslons or this permit ah all be
deemed revoked.- GAS SYSTEM OUTLI=TB O18TR1CY NO. PROCESSED 13Y
LICENSED CONTRACTORS I DECLARATMN OUTLET$OVER
T hereby affirm that I.am licensed undef proviafons of Chapter [ma
5 PER SYSTEM
9 (commencfpg with Section 7000)of Division 3 of the Bust- FINAL
noes and Profe4dona Code, and my license Is in full force and DATE VALIDATION
effbcf. VINAL
�Q
License,Numb b�' r� Lip.Clan � � BY
BY
Contra f &1g: Datej�
I'am exempt from the 11cens4ng requlrements'as.I am a k fee
licensed architect or a registered pti ofossion al engineerPLUMBING P�fl MI T 18$lJ I N GPEE;
acting In my profmIalonal. capacity' (Section 7051, Bus-
iness and Professions Code). TOTAL FSE
Lic_or R¢g.No. Data applloant
I-IOME OWNER-BUILDER DECLARATION
I hereby aftitm that I alar exempt from the Contractor's
License Law for the following reason (Section 1031.5, Bust- City Tat.No.
ness and Professions Code): $5.6 0 2 A
L as owner of the property, em exclusively contracting r
wfth licensed contractors to construct the project # 0 0 0 0 0 5
(Section 7044. Bustuags and Profeasdons.Code).
'
CONSTRUCTION LENDING AGENCY24.50
I hereby affirm that there Is a construction lending agency 0"0'024,5 0 6
for the performance of the work for which this permk Is
issued(Sec.3097,Civ.C.). 0'Qi 2-82
Lender's Name_
Lender's Address
I certify that I have read this application and state thaf the
above Information is correct.I agree to comply with all County
ordinances and State laws regulating- Plumbing, and hereby SEE REVERSE FOR EXPLANATORY LANGUAGE
authorise representatives of this County to anter upon the
sbo mentioned'property for inspection purposes.
Signature of ttee Date
COUNTY OF LOS ANGELES = TEMPLE CITY f 050$ PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 000717()019
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY G 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID ADDRESS:
ON FILE 6421 GOLDEN WEST AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNt: TEMP G 917801423
ASSESSOR INFORMATION NLmLK-. NEAREST CROSS STREET: LE14DN
5383-017-018 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: Al LOCALITY: TEMPLE CITY
07 BATHTUBS/SHOWERS 4.00 FIX 64.80
TENANT: 11 CLOTHESWASHER(S) 1.00 FIX 16.20 ISSUED ON: PRWESSEU-97T.-TIM BY: EXPIRES ON:
13 DISHWASHERS) 1.00 FIX 16.20 07/17/00 UT 01/14/01
21 HOSE BIBB(S) 2.00 FIX 32.40 il
OWNER: TEL. NO: 25 LAVATORIES/SINKS 5.00 FIX 81.00 FINAL DATE F7 BY: COCE:
CHA '�N' (626) 574-8083- 45 WATER CLOSET/URINAL 3.00 FIX 48.6Q
228 �1. PAMELA R.D. 47 WATER HEATER(S) 1.00 WTH 16.20LW
ARCADIA, G51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20 DESCRIPTION OF WORK
TOTAL FEES 319.35 PLUMBING FOR NEW ADDITION AND REI4OD9LING
RAN (626) 796-5899-
9051 E. VALLEY BLVD. SPECIAL CONDITIONS:
ROSEMEAD, CA
CONTRACTOR: TEL. NO: 5 PN(3ELES CO
HYDRO-TECH PLUMBING CORP (626) 282-3198- `� ��'y /7 SIG)LAT
315 WINTHROP DRIVE LIC. NO LINDER SLAB WORK
ALHAMBRA G 91803 C-36ARCHITECT OR ENGINEER: -Tn-.-w. +
PLASTIC Y/N METAL Y/N
FREEMAN (626) 796-
9
9 0511 VALLEY BLVD. Nlt104 LLC. MO ROSEMEAD, G 91770 021976
GAS PIPING
GAS VENT
UBUCW0G�K8ffffr-WTR-TTr ER
PLUMBING FIXTOM'
LAWN SPRINKLM
GAS TEST
Q ❑
UTILITY COMPANY NOTIFIED
ervice Tk►
* ADDITIONAL DATA ON FILE
REPORT ID- DPR263 ROUTE TO: BS0508