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Home My Public Portal About5758 KAUFFMAN AVE_Plumbing__ ;M1jiv -WORKERS'CgtMPENSATIONIDECLARATION a' - 3 ' C` ON "F R P MBI a - 20-0026 DPW 4/.87• . .A P PSL I ATI O CU N G PERMIT_ �I here�,'affirm that I have a certific'ate`of consent to self in- -76A667A: ;• _ sure,or"a certificate of Work ers'•Compensatiori:lrisurorice,`&. 'CE 817' Lab C a (REV"B/86);` certified.copy thereof-(Sec. 3800, ); ."`COUNTY OF LOS'ANGELES DEPT. OF PUBLIC WORKS - Policy No. ' Company.,• t r k' , ,, t 3 4- Certified Certified copy is-hereby fu'rnished'• 4- 4 r FOR�APPLICANT.TO FILL IN-(PRINT'OR TYPE)''• BUILDING Certified cop'y'is filed'with the county building inspection r r ADDRESS 7.S �[( yy Q,a- ' .,-;9�•1 , �•r: . c °• ;r', , NUMBER - ` FIXTURE OR ITEMdepartment FEE •LOCA'LITY a WATER CLOSET(TOILET), c a Date APPlicani, - g._ NEAREST. r' CROSS ST- +•/Lt_Cc./�I;: GERT,IFrCATE,'OF EXEMPTION FROM'WORKERS'; „ ' BATHtTUB' , K t' COMPENSATION"INSURANCE, SHOWER - OWNER -;section'rieed riot`be completed If"the,Mork'involved by > MAIL. the`pe'r`mit is for,o`rie'hundred dollars($100).or less.)', LAVATORY t'• ' ADDRESS>,,/77 I`"'certify tF dt in performan`c•e-of the work;f4 h•ich this per- . SINK` CITY» �/ �f *TEL' NO" mit is issued;I shdll�nobemploy,any-person ihiany,manne;so -A. ..� - s;l�z�t / as tb beco' a"uIblect''to the Workers' perisahon s � DISHWASHER X.• r CONTRACTOR` S Date°�' Applicanir CLOTHES WASHER' r NOTIC T 'AFPL'ICANT:' If; 6fter''makm thi`Certifi at ADDRESS g- c e 0 SWIMMING POOL RECEPTOR s.; empnon,�;you should become.sub�ect to-,the orkers'Compen- CITY'' TEL NO sationprovis ons•of the Ldkior Code; you-must fortliwUh comp- LAWN SPRINKLER SYSTEM , ly.•'with such;provisions'o�this perrriit's'aIl' 'eemed•revok= STATE?' LIC ' ed". <_ :. :� 7 . `�` ,. 9 WATER•HEATERLICENSE NO CLASS ->,`•y LICENSED CONTRACTORS'DECLARATION' ,,^ ' -•_ ' DISTRj�NO PRO ESSED BY j GAS-SYSTEM... yy OUTLETS- -i 1' I hereby;aff,iim that I am,licensed,utc nder provisions•of Chapter d,' fa. rJ _ 9(commencing"wlth'Section 7000)'of.Divis on'3 of the Business -OUTLETS,OVER and Professions Code, and my•,license'is m full force and ef-•, 5 PER SYSTEM FINAL VAL TION , a fect' ' i DATE License Number °+ Lic.'Class' ( v pp� l� b U r n, FINAL fS y BY .O Controcto� '"` Date I"a ,'exempt under Sec: (/y (�• t W B.BP C`-foe-this' reason' PIGrI CFl@CIC fee DatePLUMBING"PERMIT ISSUING FEE $ V� .Signature F TOTAL FEE 9 13 SINGLE FAMILY" r. .t�.O 6 • HOME OWNER-BUILDER DECL`A'RATION Plan check ci pR dnt: #:oo`o 0 o:'e 5, Thereby affirm'tha't I am exempt from the Contrdctor's'License 'Na'me Law'for the following' reason (Sectwn,7031 5,',Business`.ond -" C(,.o;0 3 4 5-0 P�ofe,ssionsCode) ' :• Address `�U ]�� .,' /7 1 C'Y• W -wet* •gym. r:%`6`613 _: 1', as ownerrof the property, viill dothe work and the Gty_' .C� i4 Tel No 4 structure:is not intended or,offered forksale;(Sechon"7044; "(� 0 q;_�$�8 Business d'nd Professions Code) 'ta CONSTRUCTION LENDING.AGENCY, - 'A ',�ir - '•r" - - �i 'r - _ �s I,Fier'eby affirm-that'%ere is.a construction lending agency for '- the performarce.6f the,work,'for•which,,this permit•is•issued •r (`Sec. 3097.'Gv`-C.•). �' �-,r - • F,;,�:!°4¢f`,`y- .. ,tea �' 1 ti• Y '� ., r _ 'S�- "' wl c•'.I Lender's Name- 'Lender's Address a, M I certify.,that.I"haye,read this'application'ond'state thgtsthe i • :i,, ;'r � '« z b' <' rte' above•infoimation is correct' 6agree'to`comply with gll`County ''a .ordinances and State-laws regulahng.Plumbing, and hereby. authon'ze'representatrves of this County to enter upon the ° s abov entioned ro r for inspection rpo s- ; ' G1 .� SEE REVERSE FOR EXPLANATORY LANGUAGE _ 5 gnature of er, 4ttee" Date. '_ }. 't WORKERS' COMPEN20-0026 DPW 4/87 SATION DECLARATION APPLICATION FOR PLUMBING .PERMIT I'hereijy, dff�m tF at have a certificate of consent to self in- 76A667A sure;�br a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) certified copy thereof (Sec. 3800, Lab. C.), COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company El Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING 7s� Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET(TOILET) . Date Applicant NEAREST BATH TUB CROSS ST. `CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER Al I (This section need not be completed if the work involved by MAIL 'L / the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS �T [.o We- I certify that in the performance.of the work for which this per- SINK q mit is issued, I shall not employ any person in any manner so CITY /�r� j TEL. NO. as to beco e s bject to the mpensa io a ///��1 IIS �!y DISHWASHER CONTRACTOR Date �� Applicant CLOTHES WASHER ADDRESS NOTICE70 APPLICANT: If, after ma ing this ertificate f' - SWIMMING POOL RECEPTOR emption, you should become subject to the orkers'Compen- CITY TEL. NO. cation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICC. P OCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER a and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATIO >_ fect. DATE a. License Number Lic. Class U FINAL cc Contractor Date BY 0 I am exempt under Sec. La B.BP.C. for this reason ► g Plan check fee - Date: PLUMBING PERMIT ISSUING FEE $ Signature TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant ZZ,sl� I hereby affirm that I am exempt from the Contractor's License Name OFyP f Law for the following reason (Section 7031.5, Business and Professions Code): Address. ` Z-OA1 1 1• 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 Cod'e). 1110.CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for o the performance of the work for'which this permit is issued a 0 6 8 8 A (Sec. 3097, Civ. C.). # o o io.0 0 5 I � 2250 Lender's Name 0 o 0 225.0 . Lender's Address I certify that I have read this application and state that the 0.9 1 b L 8 8 above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby autho z representativ of this County to enter upon the abo - ntioned r e for inspection vp7po s.b SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of PkrrAittee Date COUNTY-OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0605030018 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: - LEGAL ID: FEES PAID BUILDING ADDRESS: TR: 6561 LT: 500 UN: .003 5758 KAUFFMAN AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802505 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: WORKMAN 8587-023-016 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, C 26 MISCELLANEOUS FIXTUR 1.00 FIX 16.20 TENANT: TOTAL FEES 43.95 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 05/03/06 JK 10/30/06 OWNER: TEL. NO: FINAL DATE FINAL BY: CODE: EDIE RAMIREZ SEGAL (626) 447-1204- � 737 VAL STREET ARCD 910078525 ,DESCRIPTION OF WORK SESMIC GAS SHUT OFF VALVE APPLICANT: TEL. NO: SAME AS OWNER - SPECIAL CONDITIONS: CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE SAME AS OWNER LIC. NO UNDER SLAB WORK WATER SERVICE PLASTIC YIN METAL YIN ARCHITECT OR ENGINEER: TEL. NO: ROUGH PLUMBING LIC. NO: GAS PIPING GAS VENT HOT WATER HEATER PLUMBING FIXTURES LAWN SPRINKLERS GAS TEST UTILITY COMPANY NOTIFIED CWV GRAY WATER SYSTEM 1 i REPORT ID: DPR263 ROUTE TO: BS0508