HomeMy Public PortalAbout11015 GREEN TREE LN_Plumbing__ T
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that 1 have a certificate of consent to self 76A667A
*insure, of a certificate of Workers' Comp :nsation Insuran CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3 �. C.) COUNTY OF LOS ANGELES BU ING AND SAFETY
Pal fr Compan � ,p
❑ Certified copy is hereby furnished. J /
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �
Certified copy is filed with the county building inspec- ADDRESS
ti�deparimenT. NUMBER FIXTURE OR ITEM @ FEE'1>1 LOCALITY
WATER CLOSET
Date AppliganT NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS S7. _
COMPENSATION INSURANCE SHOWER OWNE
(This section need not be completed if the work involved by MAIL .
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESji�
I certify That in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY
so as To become subject to the Workers Compensation Laws. DISHWASHER —•
CONTRACTO
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY
Compensation provisions of the Labor Code, you must forth-
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC. �rr7
deemed revoked. WATER HEATER LICENSE NO.C_� CLASS
LICENSED CONTRACTORS DECLARATION / DISTRICT NO. PR E D BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS `
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER (/(J
and Professions Code,and my license is in full force and ffect. 5 PER SYSTEM FINAL0
r ' – VALIDATI V
DATE
License Number P.�PLic. Class �
/ FINA
Contract
e4 .��� Dal / BY
I am exempt under Sec.
B.BP.C. for this reason Plan check fee
Date: 001.PLUMBING PERMIT ISSUING FEE$
Signature 21 6,2 R
TOTAL FEE
Plan check applicant # o o o o 0 5
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name o o 9 6.03,0
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
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 Address
I certify that I have read this application and state that the ►
above information is correct. 1 agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
ry}�a mer�tiet,ed- perty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0807230012
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 43111 LT: 4 11015 GREEN TREE LN
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917803676
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: 1
18573-031-055 101 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 597 GRID: D3 LOCALITY: TEMPLE CITY, Cl
1 147 WATER HEATER(S) 1.00 WTH 16.20
(TENANT: I TOTAL FEES 43.95 (ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
107/23/08 SR 01/19/09 1
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TOWNER: TEL. NO: IFINAL DATECODE:
i
EDMONDS RENDEL A (626) 579-2741- I EXPIRED:
11015 GREEN TREE LN
ITEMP 917803676 1 IDESCRIPTION OF WORK
1 IREPLACE WATER HEATER
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(APPLICANT: TEL. NO: 1 1
IHOPPING (949) 637-7117- 1 I I
IPO BOX 75343 I ISPECIAL CONDITIONS: 1
ISAN CLEMENTE 92673 1 I
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ICONTRACTOR: TEL. NO: I 1APPROVALS DATE INSPECTOR SIGNATURE
ILIQUID PLUMBING INC. (949) 637-7117- 1 1 1
IP.O.BOX 75343 LIC. NO 1 1UNDER SLAB WORK 1 I 1
ISAN CLEMENTE, CA. 92673 322064 1 I 1 I
I I IWATER SERVICE 1 I 1
(PLASTIC Y/N METAL Y/N I I 1
(ARCHITECT OR ENGINEER: TEL. NO: II
- IROUGH PLUMBING
1 LIC. NO: I
I IGAS,PIPING I
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I IGAS VENT
I IHOT WATER HEATER I I I
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I (PLUMBING FIXTURES I 1
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1 (LAWN SPRINKLERS I
IGAS TEST I I
1 11 I
1 1UTILITY COMPANY NOTIFIED( I 1
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I I IGRAY WATER SYSTEM I 1
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1 IREPORT ID: DPR263 ROUTE TO: BS0508
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