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Home My Public Portal About11006 GREEN TREE LN_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A -insure, of a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a cert '.d copy thereof (Sec. 380 C C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. '� ;73.,pony ❑ Certified copy is hereby furnished. �Z4, FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS NUMBER FIXTURE OR ITEM tion��rtment. , @FEE LOCALITY 5 WATER CLOSET .�.� Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER 0 (This section need not be completed if the work involved by SHOWER the permit is for one hundred dollars $100 or less. MAIL ��''�� P ( ) � LAVATORY �-•� ADD ESS I certify that in the performance of the work for which this SINK CITY TEL. NO permit is issued, I shall not employ any person in any manner . so as to become subject to the Workers Compensation Laws. �� DISHWASHER CONTRACTOR ;;� .¢ e Date Applicant CLOTHES WASHER ADDRESS �� NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR �'�.� � Compensation provisions of the Labor Code, you must forth- ��'L'�2.Ge� LAWN SPRINKLER SYSTEM CITY TEL. NO. / with comply with such provisions or this permit shall be STATE 9 G'/i� LI CLASS �7 deemed revoked. WATER HEATER LICENSE NO. / d LICENSED CONTRACTORS DECLARATION DISTRICT NO. O ESSED BY I hereby affirm that I am Iicensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing.with Section 7000) of Division 3 of the Business OUTLETS OVER "' and Professions Code,and my license is in full force and /effect. 5 PER SYSTEM FINAL VALID ION DATi License Number Lic. Class /�, FIN O Contract v ///�,&ee�,E Date ��/'Dr J � BY � f9 El LM I am exempt under Sec. @. B.&P.C. for this reason Plan check fee 2 1 7 A Date: PLUMBING PERMIT ISSUING FEE$ Q 5p Signature # 0 0 0 0 0 5 TOTAL FEE ' 0 0 9 b Q O SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name . 0 0 9 6 0U I hereby affirm that I am exempt from the Contractor's License Address 053 8 5 Law for the following reason (Section 7031.5, Business and UU'''' Q� Professions Code): 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 That 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 21��,, _5--1�7_y 5- Signature ofPermittee Date COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS PL 0508 97060.90025 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA PHONE: (818) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: TR: 43111 LT: 12 11006 GREEN TREE LN FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803675- ASSESSOR INFORMATIO NUMBER: NEAREST CROSS STREET: 8573-031-063 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: D3 LOCALITY: TEMPLE CITY 47 WATER HEATER(S) 1.00 WTH 16.35 TENANT: TOTAL FEES 44.10 ISSUED ON: PROCESSED BY: PLAN Y: EXPIRES ON: 06/09/97 TC 06/09/98 OWNER: TEL. NO: . FINAL DATE FINAL CODE: MANSRIPATTANAKUL,SOMSALE (818).579-2259- 11006 GREEN TREE LN TEMP 91780 DESCRIPTI W CHANGE OUT F EX TING WATER HEAT APPLICANT: TEL. NO: MR. ROOTER OF PASADENA (818) 445-8203- SPECIAL CONDITIONS: t CONTRACTOR: TEL. N0: APPROVALS DATE INSPECTOR SIGNATURE MR ROOTER OF PASADENA (818) 445-8203- 38 E HUNGINGTON #3 LIC. NO UNDER SLAB WORK ARCADIA CA 91006 706307 C36 WATER SERVICE PLASTIC Y/N METAL-Y/N ARCHITECT OR ENGINEER: TEL. N0: �� f _ ROUGH PLUMBING LIC. N0: GAS PIPING GAS VENT HOT WATER HEATER / PLUMBING FIXTURES v LAWN SPRINKLERS GAS TEST TILITY COMPAN NOTIFIED ,\ CWV GRAY WATER SYSTEM a /n REPORT ID: DPR263 ROUTE TO: BS0508