Loading...
HomeMy Public PortalAbout6009 IVAR AVE_Plumbing__ WORKERS'COMPENSATION.DECLARATION APPUC�AIMN ,FOR PLUMBING PERMOT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) CITY OF TEMPLE CITY or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.20191-6 Company SCIF 22254 (SEA® Certified copy is hereby furnished. QQ ® FOR APPLICANT,TO FILL IN(PRINT OR TYPE) BUILDING ^ Certified copy is filed.with the county building inspec- ADDRESS 6009 NO. Ivar Ave. tion department. NUMBER FIXTURE OR ITEM n FEE LOCALITY Temple Cit Dot /1/83 Applica`General Install_ WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' 7 BATH TUB CROSS ST. Langdon COMPENSATION INSURANCE SHOWER OWNER G. VanDoran (This section need not be completed if the work involved by the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL ADDRESS same I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NC285"3 574 so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR General Installation Date Applicant ` CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of 6555 West Blvd.. Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR clrY Los Angeles TEL. NO. 7532-541 Compensation provisions of The Labor Code, you must forth- LAWN SPRINKLER SYSTEM e g with comply with such provisions or this permit shall be STATE LIC. deemed revoked. ] WATER HEATER 00 LICENSE NO. 151389 CLASS C36 LICENSED CONTRACTORS DECLARATION. DISTRICNO. / PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS O (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM 6. FINAL VALIDATION O License Number 151839 Lic. Class C36 DATE FINAL Q O Contractor W.O. Prov in Date X15/55 BY „�\+ u L te FTI am exempt under Sec. � B.&P.C. for this reason Plan check fee D Date: PLUMBING PERMIT ISSUING FEE$ Signature �'' , .�e .C62� .50 TOTAL FEE 50 Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and 0'6 9,'2 A Professions Code): City Tel. No. 1 0 0 0 0`0 5 ❑ 1, as owner of the property, will do the work and the ' ' structure is not intended or offered for sale (Section D 2'- 0 1 65 O. 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 0;0'0 ] 6 5 0 cxi I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued 03,2 3—'6 3 (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the above ipformation 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 Signature of Permittee Dote COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0110100002 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: GA I ES PAID BUILDING ADDRESS: TR: 5904 LT: 117 6009 IVAR'AV . FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801522 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: ROSEMEAD 5386-011-063 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY, C 07 BATHTUBS/SHOWERS 2.00 FIX 32.40 TENANT: 25 LAVATORIES/SINKS 1.00 FIX 16.20 ISSUED ON: PROCESSED BY: PLA BY: EXPIRES ON: 45 WATER CLOSET/URINAL 1.00 FIX 16.20 10/10/01 JK 04/08/02 TOTAL FEES 92.55 OWNER: TEL. NO: FI AL DATE FINAL BY: CODE: KIM YONG H;MYUNG A (626) 285-4217- — L 6009 IVAR AV TEMP 917801522 DESCRIPTION OF WORK PLUMBING FOR ADDITION APPLICANT: TEL. NO: KIM SAM JEONG (323) 731-7267- 1742 S. BERENDO ST SPECIAL CONDITIONS: LOS ANGELES 90006 CONTRACTOR: TEL. N0: ©�� APPROVALS DATE INSPECTOR SIGNATURE SAM JEONG KIM (323) 731-7267- 1742 S. BERENDO ST LIC..NO UNDER SLAB WOR LOS ANGELES, CA 90006 710856 C36,- _ WATER SERVICE PLASTIC Y/N METAL Y/N ' y ARCHITECT OR ENGINEER: TEL. NO: WU, HAROLD PING (626) 280-4166 ROUGH PLUMBING. f .� 1168 SAN GABRIEL BLVD. LIC. NO:I SAN GABRIEL, CA NONE X1111111 GAS PIPING GAS VENT Fi Pic) �I L FRIK HOT WATER HEATER U —J- !� PLUMBING FIX URES �. " LAWN SPRINKLERS GAS TEST lug }7 UTILITY COMPANY NOTIFIEff CWV 0 _ � GRAY WATER SYSTEM REPORT ID: DPR263 ROUTE TO: BS0508