HomeMy Public PortalAbout10311 KEY WEST ST_Plumbing__ WORKERS"COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
• 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)
or(�Qa�ycertified cop thereof Sec 3800 Lob. C.) ��'�))p �p ,r� COUNTY OF LOS ANGELES BUILDING AN SAFETY
� oTcG006o�`a.-��®pony W���L! 0& /Y/uP q(
❑ �&-)
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS d C-_, kgy war
tion depaQrtment. NUMBER FIXTURE OR ITEM FEE LOCALITY
Date —�+� Appliqan C WATER CLOSET Ix &0 NEAREST
CERTIFICATE OF EXEMPTION M WORKERS' BATH TUB CROSS ST. *�
COMPENSATION I ANCE OWNER
(This section need not be complete if the work involved by 1 SHOWER �®
the permit is for one hundred dollars $100 or less. MAIL // � `
P ( ) ) LAVATORY �� 0® ADDRESS �(Q � �iy Dg
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK 0 0 CITY �(C a/l L�� TEL. NO� ^�
so as to become subject to the Workers Compensation Laws. DISHWASHER F1) /u /6/�
CONTRACTOR {1
Date Applicant CLOTHES WASHER 99 ADDRESS fit/ t5 �1r
NOTICE TO APPLICANT: If, after making this Certificate of idi �L
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR i
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY �9 17 TEL. NOQr ���_ Q�S
with comply with such provisions or this permit shall be STATE �f`®�1 ! LIC u�� ri
deemed revoked. WATER HEATER LICENSE NO., V
LICENSED CONTRACTORS DECLARATION il 00 1 DISTRICT NO. PR SED BY
GAS SYSTEM OUTLETS `�
I hereby affirm that I am licensed under provisions of Chapter 9 D t U
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER :Ii-
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
VALID ION
C[�{q� G DAT U
License Number -"/���J Lic. Class_ 29FIN
Contractor Date — BY
I am pt under Sec. �
B.&P. for this reason
Plan check fee
Date: 0S,0
,
PLUMBING PERMIT ISSUING FEE$.
Signature
TOTAL FEE b 15o
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address << 1' A
Law for the following reason (Section 7031.5, Business and 6,5 Q
Professions Code): Cito 0 76y Tel. No.
❑ I, as owner of the property, will do the work and the o 0 -76505
structureis not intended or offered for sale (Section , 0 8, 1 4-85
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
above-menti d property f r s ection purposes.
t g,i q SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatur Permittee Date
COUNTY OF' LOS ANGELES TEMPLE CITY # 0508 :PUUMBI'NG—PERMIT?
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS PL.0508-9705060010
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDI-NG-ADDRESS:
TR: 36735 LT: 2 10311 KEY-WEST--ST
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803477
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
8585-018-066 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: C4 LOCAL'ITY: TEMPLE CITY
_ 47 WATER HEATER(S) 1.00 WTH 16.35
TENANT: TOTAL FEES 44.10 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
05/06/97 TC 05/06/98
OWNER: TEL. N0: FINAL DATE -.-F AL BY: CODE:
KIM HYUN D;KYUNG A (818) 579-3151-
10311 KEY WEST ST
TEMP 917803477 DESCRIPTION F ORK
CHANGE OUT Q XISTING WATER HEA R
APPLICANT: TEL. N0:
MARSH PLUMBING (818) 407-1247-
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
MARSH PLUMBING (818) 407-1247• _
20361 PRAIRIE ST #6 LIC. NO - UNDER SLAB WORK
CHATSWORTH CA 91311 692342 C36
i� _ ,� WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: a TEL. N0:
- ROUG>I PL'UMBI��G
LIC. N0: _
^ti '•. GAS PIPING
GAS 1FFNT
HOT WATER HEATER
PLUMBING FIXTURES
e
LAWIJ SPRINKLERS
GAS TEST
UTILITY COMPANY NOTIFIED
�. CWV
GRAY WATER SYSTEM
REPORT ID: DPR263 ROUTE TO: BS0508