HomeMy Public PortalAbout6443 GOLDEN WEST AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 7awarw
I hereby affirm that I have o certificate of consent to self a,r (z-.ao) APPLICATION FOR PLUMBING PERMIT
insut•e, or a certtf{cate of Workers'Compensation Insurance,or
■certified copy theraof(Sec.3800,Lab.C.)
COUNTY OF LOS ANGELES 13UILDINa r SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL LN (PRINT OR TYPE) BUILDIN
Certified copy Is filed with unty ndLng Inspection NUMBER FIXTURE OR ITEM FEE ADpq
de m t. LOCALITY V
Date_ Applicant WATER CLOSET NEAREST
AV I BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
LAVATORY MAIL }
(Thli section need not be c, e . if the.work i�olred A D D R ESS
y by the permit is for one h= doRm ($100) or Iesa.) SINKCITY �.+,..L61i
IC .
I certify that In the performance of the work for which this DISHWASHER
permit It Issued, I shall not employ any person In any mann et CONTRACTOR 0
so as to/b aq�me subject tothe p tion Laws, CLOTHES WASHER ADDRESS Q
Data(�LliG.APPIIr•n SWIMMING POOL RECEPTOel
R
NOTICE TO APPLICANT: If,titer this Certificate ofCITY E.L.TN ZZ
Examption, you should become subject to the Worker' LAWN SPRINKLER SYSTEM STATE LIC.
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be WATER HEATER LICENSE NO. CLASS
deemed revoked. DISTRICT NO. 2PESSED BY
' qA8 SYSTEM OUTLETS r
LICENSEV CONTRAC'T'ORS DECLARATIONOUTLETS OVER &��'
I hereby affirm that I am licensed under provislons of Chapter 6 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Buil- FINAL /
news and Professions Code, and my license is In fun force and HATE I ' VALIDATION
effect.
FINAL ,
License Numb Lic.Clan SY GZ_.
Contract Data
I am exam from the licensing requirements as I am ■ Plan check fee
licensed erchitect or a registered professional engineer PLUMBING PERMIT ISSUING FEE¢
acting in my profeasionbl capackty (Section 7051, Bur
mess end Professions Code). TOTAL FEE
LIc.or Reg.No., _Data Plan check applicant
HOME OWNERrBUILDER DECLARATION """' ;2.2 5 9.7 A _
I hereby affirm that I ■m exempt from the Contractor's Addreeo Wo 0 0 0 0 5
Licanes use Law for the folode): ns reason (Section.7031.5, Buri- City T«. FINAL®� 0 0 1 2 5
neu and ow Professions Code): r ,E 1HA E�16
I, ca owner of the property, am exclusively contracting d
with licensed contractors to construct the project 1 2505
(Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 82
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 Namq `
Lender's Address
I certify that I have read this application and state that the
above Information 4 correct.I agree to comply with an County
ordinances and State laws regulating Plumbing, and hereby SEE REVERSE FOR EXPLANATORY LANGUAGE
aut representatives of this County to enter 4pep the
also do p y for inspection p
2
Signa of Frarmittee Date
COUNTY OF IAS ANGHLE.S TEMPLE CITY 9 0508 PLUMBING PERMIT
DEPARTM]3NT OF PUBLIC NORKS 9701 IAS TUNAS PL 0508 0709050007
BUILDING AND SAFE'T'Y / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FRES PAID BUI TNG ADDRESS:
ON FILE 6443 GOLDEN W&9T AV
FEE DESCRIPTION: QUAbTTTTY: DOM: AMOUNT: TE34P CA 917801423
ASSR,SSOR INFQ MATION NUMBER t NEAREST CROM STREST:
5383-016-003 01 PE U41T ISSUANCE FEE 27.75 THCIMAS PAGE: 597 GRID: Al IOCISITY: TENS CITY, C
07 BATHTUBS/SHOWERB 1.00 FIX 16.20
TENANT: 25 LAVATOR1S9/SINXS 1.00 FII 16.20 ISSUED ON: PRDCESSED BY: PLAN BY: EXPIRES ON:
45 14ATER CLOSET/UR71VSL 1.00 FIX 16.20 09/d5/07 SR 03/03/08
TOTAL FEFS 76.35
ONICER: TEL. NO: F DATEF CODE:
JO[EN FONG
6443 GOLDEN NES! �; Y
TEMPLE CITY CA 91780 DESCRIPTION OF SARK
PLUMBING FOR NEW BATI-IRDOM
APPLICANT: TEL. NO:
TAM (626) 280-8660-
1900 S. DEL MAR AVE. SPECIAL CONDITIONS:
SAN GAHRZRL CA 91766
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIC$UITURS
SO=S DSVEI,OP�= CONSTRUCTION (626) 280-8660-
1900 S. DEL MAR AVENUE #205 LIC. 190 UNDER SLAB WORK l
SAN GABRIEL, CA 91766 895967 B
MATER SERVICY
PLASTIC Y/N M&-fAL Y/N
AACTfi1'TECT OR ENGINEER: TSL. NO:
ROUGH PLUMBING
LIC. NO:
GAS PIPINFG
GAS VENT
HOT WATER cram
PIAASING FIXTURL9
LANK SPR 2['fJMS
GAS TEST
UTPILITY COMPANY NIOTI=
CwV
GRAY NATER SYSTEM
REPORT ID: DPR263 ROUTE TO: BS0508