HomeMy Public PortalAbout5009 KAUFFMAN AVE_Plumbing__ WORKERS' COMPENSATION iJ�CL�F• ONkva: f pis IPPLO ATOO8�1 O PL)U1n�E �fi� Pf �G OY
I.hereby affirm that-1 have a certificate otcons6 ! selfd, r ,
insure, or a certificate of Workers' Compensation Insurahce;"-.
or a certified copy thereof.(Sec:3800 L_ab:`.) {r BUILDINlG AND SAFETY
.tr C011f�llY OF'L`QS ANGELES—
Policy No.' Company ) `P % p"
❑ Certified copy is hereby furnished. ." f - BUILDING
FOR APPLICANT TO FILL IN(PRINT OR.TYPE)
❑ Certified copy is filed with the•county building inspec t ADDRESS
tion department. ' # NUMBER FIXTURE-OR ITEM FEE LOCALITY
7-7 i WATERCLOSET_
�C1��-
CLOSET
Y
Dote Applicant, y k x - �" NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' i CROSS'ST`
BATH TUB _
COMPENSATION INSURANCE: OWNER �r
(This section need not be completed if the work involved by `* { ° SHOWER -� f�/ 11 �✓(t��/� Gh l
MAIL'
the permit is for one-hundred dollars (j100)or less.) ( I •`LAVATORY ry
�'t Z ADDRESS !.C - _ c
I certify that in the performance of the work for which this: z, -1 . �:-
SINK - CITY f—r r
permit is issued, I shall not employ any person in any manner " j L` `�. TEL. NO
�t�, r�r✓ r� '�j
so as to become subject to the Workers'.Compensation Laws.">: 1 -
p v <='• DISHWASHER CONTRACTOR
J
Date - S Applicant CLOTHES WASHER ADDRESS 1
NOTICE TO APPLICANT: 1f, after' aking this Certificate of
Exemption, you should becom subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY ( TEL. NO. C
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRI T N . OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9
GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER M.
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL j ' , VALID (ON O
DATE
License Number Lic. Class t�
FINAL / l r 0
Contractor Date BY (� IJ
!/
❑ am exempt under Sec. Y/%G/ zA
B.BP.C. for this reason �/� zzz((( 3 ',�j �{ zPlan check fee ,^�-,,
Date: ,1
PLUMBING PERMIT ISSUING FEE$ V S ;... # o 0 0 ° 0 5
Signature
TOTAL'FEE 1 a.° 5 a 5 O
Plan check applicant =
SINGLE FAMILY ° ° ° 5&5 O
HOME OWNER-BUILDER DECLARATION Nome
I hereby affirm that I am exempt from the Contractor's LicenseAddress U (' )9—a 5
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
i 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 I certify that I have read this application and state that the 1711111
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 prop rty or inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
S nature of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PPERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS � L'I) ING Pi-0508-9905190004
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID Bb'lt-D'I'NG-ADDRESS:
TR: 14832 LT: 75009 KAUFFMAW-)AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: P CA_97-7803944
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
8589-017-008 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A4 LOCALITY: TEMPLE CITY
25 LAVATORIES/SINKS 1.00 FIX 16.20
TENANT: 45 WATER CLOSET/URINAL 1.00 FIX 16.20 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
TOTAL FEES .60.15 05/19/99 UT 11/15/99
OWNER: TEL. NO: FINAL DATE FINAL BY: CODE:
SWANTON JOHN W;SARA G TRS _ (626) 286-8519- $ 19 O
5009 KAUFFMAN AV
TEMP 917803944 DESCRIPTION OF WORK
PLUMBING FOR WORK SHOP
APPLICANT: TEL. NO:
SAME AS OWNER
SPECIAL CONDITIONS:
CONTRACTOR:
TEL. NO: - ®� ®�/��� APPROVALS DATE INSPECTOR GNATURE
SAME AO
LIC. NO UNDER SLAB WORK
WATER SERVICE J
PLASTIC Y/N -METAL Y/N
ARCHITECT OR ENGINEER: TEL. NO:
ROUGH PLUMBING
LIC. NO•/
1111111 GAS PIPING
U
n nn C 0 GAS VENT
G� 2")ILLL���I 1�K( HOT WATER HEATER
JJJ lJ v�J PLUMBING FIXTURES
0 0 Ei LAWN SPRINKLERS.
Q _ n' GAS TEST
❑ o �Sj UTILITY COMPANY NOTIFIED
CWV
c
service"T �
GRAY WATER SYSTEM
,7k,
REPORT ID: DPR263 ROUTE TO: BS0508