HomeMy Public PortalAbout11011 GREEN TREE LN_Plumbing__ �r! WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
,VI hereby affirm that I have a certificate of consent to self 76A667A
insur2, or a c6Ytificate of Workers' Compensation Insu nce, CE 817(REV. 10/81)
or a cer fled copy thereof (Sec. 3 ab. C.) COUNTY OF LOS ANGELES UILDING AND SAF
Pol �Compang^; /
❑ Certified copy is hereby furnishe .
FOR APPLICANT TO FILL IN(PRINT OR TYPE) - BUILDING
Certified copy is filed with the count ilding inspec- ADDRESS
ti�dtent. NUMBER FIXTURE OR ITEM @ FEE LOCALIT
WATER CLOSETDateApplica� - NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' ti BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNE
SHOWER
(This section need not be completed if the work involved by �i
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL
ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK _ CITY h TFL''fy
so as to become subject to the Workers Compensation Laws. DISHWASHER �/ Cw
._.�, CONTRACTOR 7►'"
DateADDRESS Applicant CLOTHES WASHERAll
NOTICE TO APPLICANT: If, after making this Certificate of
al
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR r �
CITY
Compensation provisions of the Labor Code, you must forth-
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC. w
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT N¢. /1OCESSED Y
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER c
and Professions Code,and m license is in full fo4,�nd effect. 5 PER SYSTEM
yFINAL VA ATION
DATE
License Numb Lic. Class �
FIN
Contracts% ./Cl�Cl � Date� BY f
EJ am exempt under Sec. LU
L
B.BP.C. for this reason �
Plan check fee 11111101
Date:
Signature PLUMBING PERMIT ISSUING FEE$ 5
g TOTAL FEE 921-64A
Plan check applicant ; o o o 0-0 5
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name 0 09600
1 hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): 0 0 og600
City Tel. No.
cx
❑ I, as owner of the property, will do the work and the 0—,(3 a 8 5
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
ab ve-menti property for inspection purposes.
� � •✓ � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signotu Permittee 15ate
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0109280004
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 43111 LT: 3 11011 GREEN TREE LN
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803676
ASSESSOR NFORM ION NUMBER: NEAREST CROSS STREET:
8573-031-054 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: D3 LOCALITY: TEMPLE CITY, C
13 DISHWASHER(S) 1.00 FIX 16.35
TENANT: TOTAL FEES 44.10 ISSUED ON: PROCESSED Y: PUN BY: EXPIRES ON:
09/28/01 VG 03/27/02
OWNER: TEL. NO: FINAL,DATE FINAL BY: CODE:
VELOZ DIANA J;PAUL (626) 592-8634-
11011 GREEN TREE LN � v
TEMP 917803676 DESCRYPTION OF WORK
DISHWASHER CHANGE OUT
APPLICANT: TEL. NO: -0�<Pe
APPLIANCE INSTALLERS INC. (562) 986-5511-
SPECIAL CONDITIONS:
CONTRACTOR: TEL. N0: APPROVALS DATE INSPECTOR SIGNATURE
APPLIANCE INSTALLERS (562) 986-5511- ���� U DER SLAB WORK
3823 INDUSTRY AVENUE LIC. NO per,
LAKEWOOD, CA 90712 594282 HIC * A/
WATER SERVICE
�A
_- >- PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: TEL. NO: ;I/;
ROUGH PLUMBING
LIC. N0: ! GAS PIPING
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES
LAWN SPRINKLERS
GAS TEST
UTILITY COMPANY NOTIFIED
CWV
GRAY WATER SYSTEM
* ADDITIONAL DATA ON FILE
REPORT ID: DPR263 ROUTE TO: BS0508