HomeMy Public PortalAbout10232 GREEN ST_Plumbing__ W«9lS6'GOMPENSA11ON DEC'-AJZATIOK -20DPW A/90APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a Odtficate of cocaertt to self In- 76A667A
surra,or a c%rtfflaate of Workers'Compensation Insurance,ory
certified copy thereof(Sec.-3800, Lab.C.
COUNTY OF LOS-ANGELES DEPT. OF PUBLIC WORKS.
Polley No-.Company
Certified copy is hereby furnished.
T OR TYPE) AUIDNG
Cbrttfled copy Is filed with the county building Inspection
APPLK'l,Nr TO FILL IN(PRI NT lon >•UB DORSS D^3� 5
��� F4CRE�� FEEdepartment. LOCALITY
Dafe Applicant WATER CLO$ET(TOILEn
CERTIFICATE OF bEYPTION FROM WORIIRS' BATH TUB CROSS ST. G .
COMPENSATION INSURANCE SrbWt - OWNER
(T}rla sectbn need not be completed IF the work IavoFved by MAJL
the p*nnit Is For a"hunted dollars($100)or Ives.) LAVATORY APDRSS
I certify that In the performance of the work for which this per- SJNK M, TEL. NO
mit Is issued, I shall not employ aoy Person In a manner so
as fo becom sulk to the Workers.Com DISNWASHE9
001J1-RACiOR ,
Oats Applicant C10TFff5 WASHER
aDbes
NQTICE TO CANT: If,,offer ma Ing thj1sXlfI.te of Ex- SWVAhkj POOL RECEPIC(t
emption,you should become iublectto orkers'Compen- OhY Tom•NO.
sation provisions of fhe Labor Code,you must forthwith comp- LAWN gpRINIGJ�R SY$TrJ
ly with sqch prbvhrorrs or this permit shall be deemed reyok- -51",'T
g au ,
ed. WATER HEATER
LICENSED CONTRACTORS DECLARATiOR Dt3TRtCT S
I hereby affirm that I am licensed under provitions.of Chapter GAS SYSTEM OUTLETS �$ •
9(t ommendng with Section 7000)of bIvItIon 3 of the Business '502
S OVEit
and Professions Code, and ray license is In full f w end of- SPet SYSi5ti1 FINAL TION
fart. HCSE BIB
DATE7-47
-r�--T— �
License Number Lrc. Class
FINAL yy(�sJV
V
Date BY
Contractor.
O
I am exempt under Sec.
41
BAP.C- for this reason Plan Check fes ,
Date: PLUMBING PERM17 ISSUING FEE# 27 30
e
IOTA M1907
o
$igndture TOTAL I E y ��y$D Fy/ t1.+'-► d 1y
HOME OWNEROSINOU LDERIDKIARATION LY _. Plan check appllc0gt (���yy�yy
I heroby affirm that I am exempt from the Contractors Lm
icensb Nae °w
Law for the following retrsorl-(Section 7031.5, Business and _
Professions Code): Address I Z 57
I, as owner of the prop", will do the work and the City Tel. 11
structure Is not Intended br offered for apl*(lection 704, E72
Buslneso.and PYofeWons Code).
CON$TRUCT1ON LENDING AGRgCY
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is hoed
(Sec.3097, Civ. C.). _
Lerrdert Name
Lender's Address
I gartlfy that I have read this application and sfdN That the
above Information Is correct. I agree to comply with all County
ordinances and State laws""9ulatlgg Plumb4ng, and hereby
authorize Fepr tives of this County to u the
above- for Inspection pu
SEE REVERSE FOR EXPLANATORY LANGUAGE,9
slgrwur.of Ittee Dc
COUNTY OF LOS ADGEL9_9 TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1001270001
BUILDING AND SAFSi'Y / LAND DEVELOPMENT TEMPLE. CITY CA 91780
PHONE: (616) 285-0488 ETT:
LEGAL ID: FEES PAID 13D=ZRG ADiRESS:
ON FITS 10232 GREEN ST
FEE DESCRIPTION: QUANTITY: 0OM: AMOUNT: TEMP CA 917803336
ASSESSOR INFORMATION NUMBER: NEAREST CROSS 3TR=:
8585-006-023 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: BA L4)CALITY: TEMPLE CITY, C
25 LAVATORIES/SINKS 1.00 FII 16.20
TENANT: TOIIAL FEFB 43.95 ISSUED ON: PROCESSED BY: PLAN BY: RYPIRES ON:
01/27/10 SR 01/27/11
090IER: TEL. NO: FINAL DATE FTNAL BY: CODE:
BALTffi2RA/VINCENT, BARBARA (626) 452-0561- MH --1
--1N
10232 GREEN ST �J
TE14P 917803336 DESCRIPTION OF FORK
PLUMBING FOR 1/2 BATHROOM
APPLICANT: TEL. 190:
SAME AS O91NUR
SPRCSAL CONDITIONS:
Oki Wot-�
CONTRACTOR: TEL. NO: APPR0VAXS DATE INSPECTOR SIGNATURE
SANE AS OWNER -
LIC. NO UNDER SLAB WORK
i(ATER SERVICE
PLASTIC Y/Y M= YIN
ARCHITECT OR ENGINEER: TEL. NO:
- ROUGH PLUMBING
I.IC. NO:
GAS PIPING
GAS VENT
HOT WATER HFi1T{iR
PLUMBING FIX'T'URES _
LANK SPRINXIER.S
GAS TEST
UTILITY COMPANY NOTIFIED
CMV
GRAY FATRR SYSTEM
REPORT ID: DPR-263 ROUTE TO: 1390508