HomeMy Public PortalAbout6109 HART AVE_Plumbing__ %WORKER'S COMPENSAT19N DECLARATION 20-0026 DPW 9/89 n (� �, n
I,he5eby a.`..firm�tha::I•have"a certificate of consent to self insure, 76A667A AP�p LL-�IVJA���IICI FOR PLUMBNG P[�[�NT
o r�a'cefiificCte or Worker's Compensation Insurance, or�.a certified
copy,
raaf•($ec.3800 Lab.C.)
Policy No.' Company
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
1D Certified copy is hereby furnished. BUILDING !! t
• FOR APPLICANT TO.FILL IN(PRINT OR TYPE)
ADDRESS w
Certified copy is filed with the county building inspection _
department. A NUMBER FIXTURE OR ITEM @ FEE LOCALITY -,✓ _
Date /7,//-',/;j Applicant
• M •'� WATER CLOSET �'�- � NEAREST
CERTIFICATE OF EXEMPTION FR WORKERS' 3 BATH TUB _ ry CROSS ST U�/Ii/I�/dL
COMPENSATION INSURANCE O► ASSESSOR
(This section need not be completed if the work involved by the SHOWER 0•.• MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) LAVATORY it OWNER A�J-" - /i—
I certify that in the performance of the work for which this permit �J MAIL
r _
is issued, I shall not employ any person in any manner so as to SINK ADDRESS f V
become subject to the Workers'Compensation Law / ,��
DISWASHER D CITY-'I" 'L-�1 i'} TEL.NO.
Date Applicant I' l CLOTHES WASHER `f
NOTICE O IC
If, after king this Certifi ate of Q ' CONTRACTOR
Exemption,you should become subject t the Workers' Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO. yycJ/�(JZ�. __
WATER HEATER L
I hereby affirm that I am licensed under provisions of Chapter 9 STATEU LIC.
(commencing with Section 7000) of Division 3 of the Business and LICENSE NO. CLASS
Professions Code,and my license is in full force and effect. I
GAS SYSTEM OUTLETS V
OUTLETS OVER DISTRICT NO. PROCESSED BY cc
5 PER SYSTEM0 O
License Numberrl'C� , / Lic.Class C ~
FINAL VALIDATION a
DATE
Contractort�7 Date .,•?
/41 O7
El
FINAL Z
I am ex pt under Sec. BY
r
BAP.C.for this reason
Plan check fee
Date:
Signature PLUMBING PERMIT ISSUING FEE$ �3 bt7
TOTAL FEE ,dv
SINGLE FAMILY
Plan check applicant, 5
�
HOME OWNER-BUILDER DECLARATION Name __ I :a
I hereby affirm that I,am exempt from the Contractor's License Law _
for the following reason (Section 7031.5, Business and Professions- Address — -T I j
Code):
��z'
El 1,
Tel. No.
I,as owner of the property,will do the work and the structure -,--q
is not intended or offered for sale (Section 7044, Business �4 F C AL 1•+=1'•x' _ 03
and Professions Code): Me i k;
CONSTRUCTION LENDING AGENCY r �• n c�
I hereby affirm that there is a construction lending agency for the ` fid 1�E
performance of the work for which this permit is issued (Sec. 3097,
Civ.C.)
Lender's Name r.4
1 5 n
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 above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
i
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1011150025
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT: -
ILEGAL ID: FEES PAID I BUILDING ADDRESS: 1
ITR: 5904 LT: 221 I 1 6109 HART AV 1
I (FEE DESCRIPTION: QUANTITY: DOM: AMOUNT: 1 TEMP CA 917801629
1ASSESSOR INFORMATION NUMBER: 'I NEAREST CROSS STREET:
15384-008-023 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 596 GRID: H2 LOCALITY: TEMPLE CITY, Cl
151 LOW PRS GAS 5 OUTLET 1.00 SYS 16.30
ITENANT: I TOTAL FEES cc_10 11SSUED ON: PROCESSED BY PLAN BY: 1
11/15/10 SR
I I 1 I1
(OWNER: TEL. NO: IFINAL DATE FINAL BY: CODE:
IMAASON, LARRY (626) 483-7719- - 1
16109 HART AV ������
ITEMP 917801629 1 1DESCR_PTION OF WORK - 1
I 11NSTALL NEW GAS LINE TO NEW UPSTAIRS FURNACE 1
1APPLICANT: TEL. NO: 1 I
I'CONTRERAS, CARRA (626) 286-3157- 1 _
14931 N. ENCINITA AVE ISPECIAL CONDITIONS:
TEMPLE CITY CA 91780
CONTRACTOR: TEL. NO: (APPROVALS . DATE INSPECTOR SIGNATURE
ICONNOR AIR CONDITIONING (626) 286-3157- I
14931 ENCINITA AVE LIC. NO' 1 (UNDER SLAB WORK
ITEMPLE CITY, CA 91780 403735 C20 I I I I
IWATER SERVICE
1PLASTIC YIN METAL YIN 1
1ARCHITECT OR ENGINEER: TEL, NO: I
- I 1ROUGH PLUMBING
1 LIC. NO:
IGAS PIPINGf (
1 1 IGAS VENT �O 4
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IHOT WATER HEATER
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IPLUMBING FIXTURES
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ILAWN SPRINKLERS 1 I I
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1 1 - GAS TEST
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1UTILITY COMPANY NOTIFIED( I I
I 1CWV
I (GRAY WATER SYSTEM I
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IREPORT ID: DPR263 ROUTE TO: BS0508
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