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HomeMy Public PortalAbout6236 IVAR AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION - � nnp n C A MN F©�-,�n ` 20-0026 DPW 4/90 G=AIT I!"l� !�1 i1�.1 L� 1/Vvu II�JV LSh�IUWI1 I.hereby nffir'm'that I have a certificate of consent,To self.in- 76A667A sure;or a certificate of Workers'Compensation Insurance,ora e certified copy thereof (Sec: 3800,'Lab. C.), COUNTY OF..LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company k ❑ •Certified copy is hereby furnished. BUILDING. FOR APPLICANT TO FILL IN(PRINT OR TYPE) r Certified,copy is filed with the county building inspection ADDRESS 6,2 36 „LV'tK NUMBER FIXTURE OR ITEM FEE LOCALITY department: @ P!-c frit ry WATER CLOSET(TOILET)- Ddte Applicant NEAREST BATH TUB CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' " y� COMPENSATION INSURANCE SHOWER ' OWNER T to MAS {This section need not be completed if the work involved.by MAIL the permit is for one hundred dollbis($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per SINK mit is issued, I shall not employ any person in any manner so CITY TEL. NO. qS(5—���� as to become subject to the Workers'Compensation Laws. DISHWASHER p � CONTRACTOR V),}1} [•L . TO Pct W0 lit te— .Date Applicant CLOTHES WASHER. ADDRESS' NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption,you should become subject to the-Workers'Compen- CITY TEL. NO. sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this.permit shall be deemed revok- STATE LIC. ed. WATER HEATERLICENSE No. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY 1-hereby affirm that I am licensed'under provisions of Chapter GAS SYSTEM OUTLETS �= r 9(commencing with Section 7000)of Division 3 of the Business OUTLETS'OVER ✓ �� `—"' � ��� and Professions Code, and my license is in full force and ef- 5 PER.SYSTEM' FINAL VALIDATION fecti HOSEBIB DATE License'Number Lic. Class' FINAL Contractor Date BY "GC El I am exempt under Sec. B.&P.C. for this reason CL Plan check feel_t = z� Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL.FEE + .� p i � SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that l am exempt from the Contractor's License Name ;_ €sSys I E€i `s Law.for the following reason (Section 7031.5, Business and - - ^ s Profess ions'Code): Address #4µ'I �I, as owner of the property, will,do the work and the City Tel..No. 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 ob ve-mentioned.property for insEA poses. SEE REVERSE FOR EXPLANATORY LANGUAGE Signat r of Permittee Date T COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0205290004 BUILDING AND SAFETY / LAND, DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID• FEES PAID BUILDING ADDRESS: TR: 5904 LT: 34 6236 IVAR AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801525 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LAS TUNAS 5384-001-010 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H2 LOCALITY: TEMPLE CITY 07 BATHTUBS/SHOWERS 1.00 FIX 16.20 TENANT: 13 DISHWASHER(S) 1.00 FIX 16.20 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 25 LAVATORIES/SINKS 2.00 FIX 32.40 10/18/02 JK 04/16/03 45 WATER CLOSET/URINAL 1.00 FIX 16.20 OWNER: TEL. NO: 47 WATER HEATER(S) 1.00 WTH 16.20 FINAL DATE FINAL BY: CODE: MCGRATH THOMAS P;SUZETTE G (626) 286-8435- 51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20 6236 IVAR AV TOTAL FEES 141.15 TEMP 917801525 DESCRIPTION OF WORK PLUMBING FOR ADDITION/REMODEL APPLICANT: TEL. NO: TANG (626) 793-8387- 745 EARLHAM ST SPECIAL CONDITIONS: PASADENA - CONTRACTOR: TEL. N0: F APPROVALS DATE INSPECTOR SIGNATURE -� ,� RCON (626) 398=7265 P.O.BOX 6427 LIC. NO �i �� p `: Y � UNDER-SLAB WORK ALTA DENA, CA 91003 757558 B WATER SERVICE _ PLASTIC Y/N METAL Y/N ARCHITEC OR ENGINEER: TEL N0: // ,i /' � r 7�� f i �` ROUGH PLUMBING LIC. NO ,� _ Ii it 1 ,llx� GAS PIPING GAS VENT HOT WATER HEATER PLUMBING FIXTURES - f \ LAWN SPRINKLERS /%i GAS TEST UTILITY COMPANY NOTI IED CWV ` GRAY WATER SYSTEM REPORT ID: DPR263 ROUTE TO: BS0508