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HomeMy Public PortalAbout4807 HALLOWELL AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT }, -1-Aergby affirm that I have a certificate of consent to self 76A667A insure, ©r a certificate of'Workers' Compensation Insurance, CE 817(REV. 10/81) or a ce'rtified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company F] Certified Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET /� Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB Od CROSS 5T. COMPENSATION INSURANCE OWNERrte/`" (This section need not be completed if the work involved by SHOWER MAIL Q the permit is for one hundred dollars ($100)or less.) -9- LAVATORY (j ADDRESS J I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. D so as to become subject to the Worker Compe ation Laws. DISHWASHER CONTRACTOR DateApplicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this C ificate of ADDRESSQd. Exemption, you should become subject to th Workers' SWIMMING POOL RECEPTOR CITY TEL. N r Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM ry with comply with such provisions or this permit shall be STAT 3 X LIC. deemed revoked. WATER HEATER LICENSE NO. / s J CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO P C SED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS r (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER y and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL _ VAII ATION Z" DATE License Numberj3o p Lic. Class —IL.- FINA Contract o . �— Date r BY ❑ I am exempt under Sec. :24,128A e.&P.C. for this reason g Date: Plan check fee # 0 0 0 0 0 5 PLUMBING PERMIT ISSUING FEE$ Signature � ) o,o '] &5 O TOTAL FEE Plan check applicant o 0 o 7 6 5 0 5 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name 0227-86 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): 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. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the Z266ey for inspection purposes.�� � SEE REVERSE FOR EXPLANATORY LANGUAGE - --Z' -I � gnature of Per tree Date COUNTY OF LOS ANGELES TEMPLE CITY # 0.508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0812100010 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: ILEGAL ID: FEES PAID I BUILDING ADDRESS: 1 ITR: 15098 LT: 7 1 4807 HALLOWELL AV 1 I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA 917803457 1 (ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: LOWER AZUSA 1 18585-016-015 101 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 597 GRID: CS LOCALITY: TEMPLE CITY, Cl 1 151 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20 1 (TENANT: I TOTAL FEES 43.95 (ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: I 1 1 112/10/08 SR 06/08/09 10WNER: TEL. NO: I (FINAL DATE FINA BY: CODE: TEL DEEB HASSAN M;FERIAL H (626) 442-4250- I 'I 14938 HALLOWELL AV 1 I- 1 ITEMP 917803458 1 1D SCR P ON OF WORK I I (REPLACE THE UNDERGROUND GAS LINE ! I I I 1APPLICANT: TEL. NO: I LUU (626) 831-3561- I 12108 PENNSYLVANIA ISPECIAL CONDITIONS: 1 ICOLTON, CA 92324 ! - 1 1 I I I I I (CONTRACTOR: TEL. NO: 1APPROVALS DATE INSPECTOR SIGNATURE I IDONG PHU LUU (626) 448-3562- 1 1 1 12108 PENNSYLVANIA AVE LIC. NO 1UNDER SLAB WORK 1 ICOLTON, CA 92324 654302 C36 I 1 I 1 IWATER SERVICE I IPLASTIC YIN METAL YIN I I I (ARCHITECT OR ENGINEER: TEL. NO: ! 1 1 - TROUGH PLUMBING 1 I 1 LIC. NO: IGAS PIPING 1 pa 1 IGAS VENT I I 1I IHOT WATER HEATER I I I I I I I 1 1PLUMBING FIXTURES I I I I I I (LAWN SPRINKLERS I I I I I I I I IGAS TESTI I (UTILITY COMPANY NOTIFIED r 1 ICWV I I ! (GRAS.' WATER SYSTEM I I I I I I I I I I I I I I I I I I I I I I I ! I I I I I I I I I I I I I i I I I I I I I I I I I 1 I I i I I I I I I I I I I I I I I I I f I I 1 (REPORT ID: DPR263 ROUTE TO: BS0508 I 1