HomeMy Public PortalAbout10318 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�a(,(c�ePrtifieWp thereof (Seyc. 3800,, LLgaab.. C.) p� yyq COUNTY OF LOS ANGELES BUILDING AND SAFETY
Percy�l�ya- O�~� P nY AJ D91 Pfaf K-
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS �
NUMBER FIXTURE OR ITEM FEE LOCALITY
tion department. @ L T
Date - Applicant WATER CLOSET OX IN& NEAREST Mud a=
CERTIFICATE OF EXEMPTION OM WORKERS' BATH TUB 0 5 CROSS ST.
COMPENSATION IN RANCE 1 OWNER FA,V
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL
I certify that in the performance of the work for which this A
0 d ADDRESS rp i
permit is issued, I shall not employ any person in any manner SINK V CITY. l L ick TEL. NO.
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so as to become subject to the Workers'Compensation Laws. DISHWASHER �!v J1i 'AgK C
V CONTRACTOR909 UM)Tf, At6 C
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR 6
Exemption, you should become subject to the Workers' CITY TEL. NO. / pp
Compensation provisions of the Labor Code, you must forth- 91 - go
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM
P Y P P STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. Ov CLASS C!
LICENSED CONTRACTORS DECLARATIONDISTRICT NO. PR CESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM 15, OUTLETS St /��/
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER (�o
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM
/� FINA �— VALI ATION
License Number 195A0 f Lic. Class_ DAT �/ V
- 6 ►
Contractor Date B �
❑ I am ee pt under Sec.
B.&P.C. or this reason
Plan check fee g
Date: PLUMBING PERMIT ISSUING FEE$ U
Signature
TOTAL FEE 16
Plan check applicant
SINGLE FAMILY ;R 2 71.4 A
HOME OWNER-BUILDER DECLARATION Name # o 0 o o 0 5
1 hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and o o 7 6,5 Q
Professions Code): City Tel. No. o 0 0 7 6 5 Q
I, as owner of the property, will do the work and the v
structure is not intended or offered for sale (Section
7044, Business and Professions Code). Q 8 - 5
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-mentioned property for inspection purposes. o
SEE REVERSE FOR EXPLANATORY LANGUAGE
-1 y ^fir
Signao of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS PL 0508 9808280003
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 36735 LT: 8 10318 KEY WEST ST
_ FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803476
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
8585-018-072 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY, C
07 BATHTUBS/SHOWERS 1.00 FIX 16.20
TENANT: TOTAL FEES 43.95 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
08/28/98 VG 08/28/99
OWNER: TEL. NO: FINAL DATE FINAL BY: E:
RYKER, BETH (626) 448-6304
10318 KEY WEST ST 10- Z
TEMP 917803476 DESCRIPTION OF WORK
PLUMBING FOR SHOWER
APPLICANT: TEL. NO:
S & N CONSTRUCTION (626) 792-2020-
P. 0. BOX 93194 -.-_-__ SPECIAL CONDITIONS:
PASADENA, CA 91109
CONTRACTOR: TEL. N0: APPROVALS DATE INSPECTOR SIGNATURE
S & N CONSTRUCTION (626) 792-2020-
P. 0. BOX 93194 LIC. NO UNDER SLAB WORK
PASADENA, CA 91109 6845416
e'
�i WATER SERVICE
IV PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGIN ER: TEL. NO:
ROUGH PLUMBING
LIC. NO: r----� t '��1111111� -2-fo
GAS PIPING
- GAS VENT
HOT WATER HEATER
-- - - - __
PLUMBING FIXTURES
- P ;
LAWN SPRINKLERS
GAS TEST
UTILITY COMPANY NOTIFIED
CWV
GRAY WATER SYSTEM
REPORT ID: DPR263 ROUTE TO: BS0508