HomeMy Public PortalAbout10336 KEY WEST ST_Plumbing__ WORKERS'-COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
R`sure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
oprp cer[[t'ff' cl co y tlhe�reof (Sec. 3800,,Lar b. C.) ®��' COUNTY OF LOS ANGELES BUILDING ANDS FETY
Folic .o� "" C��® A�1�'(1G 'Ef1��f�. u t uw---
❑ Certified copy is hereby furnished. f
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ,.� •�
10 Certified copy is filed with the county building inspec- ADDRESS, :.
tion department. NUMBER FIXTURE OR ITEM @ FEE
��g� LOCALITY
Dote-"-35' AppliqonlOy WATER CLOSET V" NEAREST
CERTIFICATE OF EXEMPTION F OM WORKERS' 1 BATH TUB &0 CROSS ST.
COMPENSATION IN RANCE OWNER
(This section need not be completed if the work involved by SHOWER'® '
the permit is for one hundred dollars $100 or less. MAIL
P ( ) LAVATORY ADDRESS AG
I certify that in the performance of the work for which this A �,.�^
permit is issued, I shall not employ any person in any manner U SINK CITY sI� fqTEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER N►
CONTRACTOR 16 J�„/%
Date Applicant C CLOTHES WASHER ADDRESS ro
NOTICE TO APPLICANT: If, after making this Certificate of a L .
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY /� /�y9 TEL. NO��yi/�o�
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM � � �”' �� 11
with comply with such provisions or this permit shall be STATE LIC. fp
deemed revoked. WATER HEATER LICENSE NO. 5 CLASS C,3
LICENSED CONTRACTORS DECLARATION DISTRICT N e CESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 8 GAS SYSTEM OUTLETS
(commencing with Section 7000 of Division 3 of the Business
( 9 ) OUTLETS OVER �
and Professions Code,and my License is in full force and effect. 5 PER SYSTEM FINAL VAL ATION
,�.. ss���� DAT — Z Z
License Number 7�quo Lic. Class�4�_
BI AB
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Contractor Date 4�
�D
I ame e pt under Sec.
B.&P.C. or this reason I
Plan check fee Poo. �
Date: ,
PLUMBING PERMIT ISSUING FEE$
Signature Jo
TOTAL FEE ;2 2 7 Q 9 A
Plan check applicant
SINGLE FAMILY # o o o o o 5
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address I o o 76.5 Q
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. - 76500'
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section ® O R 1 4-S 5
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-mentioned property for inspection purposes. .
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signal of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1203280003
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 36735 LT: 11 1 1 10336 KEY WEST ST 1
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917803476 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: I
18585-018-075 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY, Cl
1 107 BATHTUBS/SHOWERS 1.00 FIX 16.20 I I
1TENANT: 1 TOTAL FEES 44.00 11SSUED ON: PROCESSED BY: PLAN BY:
I I 103/28/12 SR
I
(OWNER: TEL. NO: I IFINAL DATE FINAL BY: CODE: 1
ISHIRAZI, ALI
110336 KEY WEST ST 1 1
ITEMP 917803476 IDE CK PTION OF WORK 1
1 IBATHROOM REMODELING DRAIN RELOCATE TO CENTER OF SHOWER 1
1 (ENCLOSURE AND NEW SHOWER VALVE INSTALLATION I
(APPLICANT: TEL. NO: 1 1 I
IHOME IMPROVEMENT & MAINTENANCE (626) 733-2228- 1 1
118824 E. ARMSTEAD ST 1 ISPECIAL CONDITIONS:
1AZUSA, CA 91702 I
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ICONTRACTOR: TEL. NO: I 1APPROVALS DATE INSPECTOR SIGNATURE 1
IHOME IMPROVEMENT AND MAINTENANCE (626) 738-2228- 1 1
118824 E. ARMSTEAD STREET LIC. NO 1 1UNDER SLAB WORK 1
1AZUSA, CA 91702 913493 B 1 I I
I I IWATER SERVICE
I I IPLASTIC YIN METAL YIN 1 1 1
(ARCHITECT OR ENGINEER: TEL. NO: 1 I I 1 1
I - 1 IROUGH PLUMBING
1 LIC. NO: I1
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1 IGAS VENT I I
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I 1 IPLUMBING FIXTURES I 1 1
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ILAWN SPRINKLERS I
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IGAS TEST
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1 1UTILITY COMPANY NOTIFIEDI I I
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1 I IGRAY WATER SYSTEM
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IREPORT ID: DPR263 ROUTE TO: BS0508
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