HomeMy Public PortalAbout10511 KEY WEST ST_Plumbing__ WORKERS' COMPENSATION'DECLARATION APPLICATION FOR PLUMBING PERMIT
I heresy affirm that I have a certificate of consent to self " 76A667A'
r , a
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV 10/81) 1 �°
or a certified copy thereof (Sec 3800, Lab C ) COUNTY OF-LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished ` p wo p
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ��/ = f
Certified copy is filed with the county building mADDRESS � Jspec- S'°
tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY �� I r
f WATER CLOSET I
ra
Date Applicant / " NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'" / BATH TUB CROSS ST
COMPENSATION INSURANCE
SHOWER OWNER •r"
(This section need not be completed if the work involved by MAILADDRESS S / r
the permit is for one hundred dollars ($100)or less.) LAVATORY - Lit
/ ' aA a7
I certify that m the performance of the work for which this _ t �
permit is issued, I shall not employ any person m y manner SINK CITY = ` NO * tt
so as to become subject to the Worker 'Co en tion La s DISHWASHER ` I �T J�
' CONTRACTOR '
Date �_ _� Applicant CLOTHES WASHER ADDRESS
NOTICE;TO APPLI ANT If, 'after makin this Certificate of
Exemption, you should 'become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL NO
LAWN SPRINKLER SYSTEM'
with comply with such provisions or this permit shall be STATE - LIC
deemed revoked WATER HEATER LICENSE NO CLASS
w, LICENSED CONTRACTORS DECLARATION I DISTRICT N P OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and effect 5 PER SYSTEM >
FINAL VALIDATION 0
License Number Lic Class DATE •,L r 9 V
FINAL
Contractor Date BY O
F-,
❑ I am exempt under Sec 3
CL
B &P C for this reason H
Plan check fee, z
Date PLUMBING PERMIT ISSUING FEE$ 0 J a
Signature
TOTAL FEE d
Plan check applicant 2 5 4'A
' SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name # o o 0 0 o 5
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031 5, Business and 2 - ,- 465 0
Professions Code) City Tel No o xo 4 6r5 0
❑ I' as
owner of the property, will do the work and the f
structure is not intended or offered for sale (Section , o0'7.0 9-8 4
7044, Business`and Prbfessions Code)
CONSTRUCTION LENDING AGENCY
Ihereby 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 w regulating Plumbing, and hereby
"authorizent rve of this Coup y to enter upon the
pop ty for in�-e n purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
ittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS _ 1 PL 0508 9612300012
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
EGA FEES PAID BUILDING ADDRESS:
TR: 11290 LT: 12 BL: C 10511 KEY WEST ST
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803463
ASSESSOR INFORMATIONB : NEAREST CROSS STREET: LA ROSA
8585-023-051 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY
47 WATER HEATER(S) 1.00 WTH 16.35
TOTAL FEES 44.10 ISSUED 0 PROCESSED : PLAN B PIRE ON:
12/30/96 TC 12/30/97
OWNER: TEL. NO: FINAL DATE FINA BY CODE:
CHEN HWAI S;ALISON C !
3611 PADUA AV1-141
CLMT 917112056 DESCRIPTION OF WORK
WATER HEATER CHANGE OUT SAME OCATION
PPLICA N0:
RBI (818) 442-3105-
\(\\� SPECIAL CONDITIONS:
CONTRACTOR: TEL. N0: APPROVALS DATE INSPECTOR SIGNATURE
RBI INC (909) 594-3686- / D �a
3940 VALLEY BLVD. UNIT D LIC. NO . o UNDER SLAB WORK
WALNUT, CA. 91789 683107 C36
WATER SERVICE
RCHITECENGINEER: TEL. s3\111O O V U o 0 Q PLASTIC PLUMBMETAL Y/N
ING
LIC. N0:
uuktGAS PIPING
6GAS VENT
NOT WATER HEATERk
PLUMBING FIXTURES
1-A99--gP N LERS
GAS TEST
UTILITY
NOTIFIED
CWV
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REPORT ID: DPR263 ROUTE TO: BS0508
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COUNTY OF LOS ANGELES TFMPLE CITY 0508 PLUMBING Ptnaf'if
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 050& 0407'3001i
BUILDING AND SAFETY / LAND DEVELOPMENT TEM^LE CITY CA 91780
PnONE: (626) 285—U488 EXT:
LEGA D'
FEE F.;l _ BUILDING ADDR S:
TR: 11290 LT: 12 BL: C 1; KEY WEST ST I
FEE DES(k:F 30N: QUANTI`Y: '_O�i: AMOUNT: TEMP CA 917803463
ASSESSOR INFOgNAT1ON NUMBER: NEAREST CROSS STREET: -a.'Ek 7UCA
8585-023-051 01 PERM iT ISSUANCE FEE 27.75 TilOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE C.-TY, C'
05 BACKFLOW DEVICE(S) 4.00 DEV 64.80
TENANT: 07 BATNTUBS/SHOWERS 1.CO plat 16.20 ISSUED O : PROCESSED BY: PLA o°. EXPI SON:
11 CLCIH:SWASHER(S) 1.00 FIY 16.20 09/23!04 JK 03/27/05
13 DISNWA.SHER(S) 1.00 FIX 16.20 _
OWNER: TEL. NO: 21 HOSE 8i86t�) 2.00 FIx 32.40 F Te FIIAL By- CODE:
Ij
CHEN HWAI S,AI_ISON C (909) 932-9259- 25 LAVATORIES/SINKS 2.00 FIX 32.40 �r
1803 LAKEU00b AVE. 45 WAIER CLOSEWURINAL GO ;'IX 16.20
UPLAND, CA 917£4 49 WATE° TREATING EQUIP 1.00 SrS 16.20 DESCRIPTION OF WORK
63 WATE_;: PT_-�ING BR/FIX 3.00 i:)11, 20.25 PIUTSING FOR NEW BATHS, NEW KiTCHFv %r LAUNDRY.
PPLICANT: TEL, NO: 64 WATE° PIPNG <= 1 1/2 TOTAL Fc00 :IN 81.00
339.60
A H ACCORD GROUP INC. (626) 308-9983—
821 S. GYRIIELO AVE SPEUI AL uONDIIIONS: -
ALHAMBPA, C4 91801
CONTRAC�Clk TEI-. NO: APPROVALS DATE INSPECTOR SIGNAIURE –
A H ACCORD GROUP INC. (626) 308-9983- i
821 S. GARFIELD AVE., #202 LIG. NO UN-0t:SSLT WORK —
ALHAMBRA CA 91801 757675 C16
WATEP, SERVICE
ARCHITECT UP ENGIN--ER: TEL. NO: PLALTIC Y/N METAL Y/N
K0, DAVIC (626) 286-1867- RCUGII PLU?46IN
5559 EARLE S. LIC. NO: ( �_
SAN GABRI EL, CA 671176BA GAS DIPING /
C-45 }!E f
-i. TER�I�ATER ---�
P!ui;31 G r XTURES z—
I✓ LAZN '-PRINKLEP.S
GLI5 TEST —
�/ IiTfI-ITy%CiPANY NOTIFIED
C' , CWJ
l� GR,lv I•IATER SYSTER
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REPORT ID: DPR263 RCUTE TO: BS0508 i –