HomeMy Public PortalAbout6012 HART AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION Ap ppUCAp IMH FOR pO UM �j G Pa ERN
I by affirm that I have a certificate of consent to self 76A667A uv is uvu u�t u�wt1
i , or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
r ertified copy thereof (Sec. 3800,•Lab:C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
acy No.216 I MAWCCornpciny . L-L
.Certified copy is hereby furnished. /
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ` t
Certified copy is filed with the county building inspec- ADDRESS d A.), . d
tion department. f NUMBER FIXTURE OR ITEM Q FEE LOCALITY i6 m � t
e� rt
Dat
1 'D 7 Applicant A� ( /q 411 WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. 45 I'?oS/A
COMPENSATION INSURANCE SHOWER OWNER �� ��� C C)&(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL
AD6 N
I certify that in the performance 'of the work for which this DRESS A/Z
permit is issued, I shall not employ any person in any manner SINK CITY�_� /� TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER C Cfl
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS a
NOTICE TO APPLICANT: If, after making this Certific to of _ a D Apci IA.*uE-
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL. NO. a
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM � 'q C) � l 6_7P77
with comply with such provisions or this permit shall be STATE J p(y 0 LIC. `3
deemed revoked.. WATER HEATER �� LICENSE NO. -` T O dt w CLASS !J
LICENSED CONTRACTORS DECLARATION DISTRICT NO. / C�
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS A
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �G y
and Professions Code,and pmy license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
License Number�� OLic. Class -6 - DATE O
4l
��� FINAL
ContractorL62d Date ' �� BY
❑ I am exempt under Sec. CL/ UJ
B.&P.C. for this reason 1 — (J V)
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ D
Signature O
TOTAL FEE
SINGLE FAMILY Plan check applicant.
HOME OWNER-BUILDER DECLARATION Name 9 3 ITA
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section.7031.5, Business and Address K o'0 0 0 0 S
Professions Code): City Tel. No. 2 0•,o'(( 2 5 0
❑ I, as owner of the property, will do the work and the
structure is not intended or offered.for sale (Section D c o f o 4 2 5 0 p
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
01 3.;0 2-.8'41
I hereby affirm that there is a construction lendirig 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 A
above-mentioned property for inspection purposes.
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ature of Permittee Date
- COUNTY OF LOS ANGELES TEMPLE.CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0712140008
BUILDING AND SAFETY J LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: FEES PAID I BUILDING'ADDRESS-- ..,q
ITR: 5904 LT: 340 1 - 1 6012 HART AV <
. - ' I
I IFEEDESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA 917801914' 1
(ASSESSOR INFORMATION NUMBER: 1 ' I NEAREST CROSS STREET: 1
15384-014-009 101 PERMIT ISSUANCE FEE 27.75 THOMAS 'PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY, Cl
1 107 BATHTUBS/SHOWERS 1.00 FIX 16.20 I 1
(TENANT: 125 LAVATORIES/SINKS 1.00 FIX 16.20 IISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: I
I 145 WATER CLOSET/URINAL 1.00 FIX 16.20 112/14/07 SR 06/11/08 1
- TOTAL-FEES 76.35 I I
10WNER: TEL. NO: I - * - - - IFINAL DPZE FINAL-BY: CODE: I
ILOEW WILLIAM;DEBORAH K;HEINZ (626) 286-1417-
16012 HART AV 1 , ..�,•� • 1 I I
ITEMP 917801914 i IYESCRIPTION OF WORK v1
i IPLUMBING FOR BATHROOM REMODEL 1
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(APPLICANT: TEL. NO: 1 1 1
IHOME SWEET HOME IMPROVEMENT (800) 994-9798-
1149925 MAGNOLIA BLVD - I 1SPECIAL CONDITIONS: 1
ISHERMAN OAKS 91403 I 1 1
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(CONTRACTOR: TEL. N0: Ii "••'` '- _ _ (APPROVALS DATE INSPECTOR SIGNATURE
IHOME SWEET HOME IMPROVEMENT (800) 994-9798- i . I 1
114925 MAGNOLIA BLVD. LIC. NO 1 - 1UNDER SLAB WORK I 1 1
ISHERMAN OAKS, CA 91403 742384 B 1 I I 1 1
I IWATER SERVICE
I 1 IPLASTIC Y/N METAL Y/N •I
1ARCHITECT OR ENGINEER: TEL. NO: I I 1
1 ROUGH PLUMBING
I LIC. No: I - I
1 1 IGAS PIPING 1 1 1
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IREPORT ID: DPR263R ROUTE TO: BS0508
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