HomeMy Public PortalAbout10021 LA ROSA DR_Plumbing__ 76Afi07-CERl7 10-613
APPLICATION `FOR PLUMBING PERMIT_
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING4NBE .DMSADRSSNA. AMICOUNTY EER ADDRESS 10021 La Rosa Dr.
WILLIAM A. JENSEN, SUPT-OF BUILDING LOCALITY Temple City
FOR APPLICANT TO FILL IN _
CROSS T. BaldWln AVE.
NUMBER FIXTURE OR ITEM - - OWNERPopp,
WATER CLOSET MAIL POPP"
1 BATH TUE ADDRESS
CITY TEL. NO-
SHOWER
2 LAVATORY CONTRACTOR Owen Bros. Plumbing
1 SIDE ADDRESS 525 N. Baldwin Aub..
DISHWASHER - CITY El Monte M. NO. GI— 37
ATE
LAUNDRY TUE AEG=ATIOCONTRACrON NO. 197184 - COUNTY]
1 CLOTHES WASHER p19TRI NO. GROUP ZONE CJ�
]- WATER HEATER. 0
1 GAS SYSTEM 'INDUSTRIAL
WASTE APPROVAL �-
INSPECTION RECORD - D-
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- W
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y
Z
$1.130 PER ITEM - -
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OR FIXTURE $ lo.00 APPROVALS DATE 'S SIGNATURE
PERMIT $ 2 100 UNDER SLAB WORK
TOTAL FEE ROUGH PLUMBING �../. (�.,r•4
.GAS PIPING
'I HEREBYACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ,
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT `^1'IT.I
WITH ALL COUNTY ORDINANCES AND STATE .LAWS REGULATING .HOT WATER HEATER w I(1" -
PLUMBING.
,y
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED'AND/OR PLUMBING FIXTURES
CE
LINSEDAS REQUIRED BY LOS ANGELES COUNTY, AND STATE OF GAS TEST W B'�4I irk /A
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE. / {
DESCRIBED RESMENTIALIPROPERXY. UTILITY CO. NOTIFIED
SIGNATURE
OF PERMITTE q !
FINAL
VALIDATION ROBERT A. WOOD
crc. M.D. CASH -.SUPERVISING MECHANICAL ENG'R
�c�a336 4 ' 0GT , 2 5 D ._' 100 �
WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have o certificate of consent to self 76A667A
insure, or a certificate of Workers' Compe atiomInsurance, CE 817(REV. 10/8I) T -
or a certified copy thereof.(Sec. 3800, Lo . .) COUNTY OF LOS ANGELES / ' BUILDI N SAFETY
Policy No.-__-_ '
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
�( Certified copy is filed with the county buil ng 'nspec- ADDRESS Q a�
NUMBER FIXTURE OR ITEM LOCALITY
tion d partment. CnJ FEE
WATER CLOSET LOCALITY/ Applican NEAREST
• ERT ICATE OF EXEMPTIO ROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars 5100 or less. MAIL �T
P ( ) ) LAVATORY ADDRESS Qpm
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 CITY TEL NOl�
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTO
: Date Applicant CLOTHES WASHER ADDRESSf' O 9
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- CITY TEL.NCS/;
Q
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM
STATE LIC.
deemed revoked. WATER HEATER XLICENSE NO.40 CLASS ` J
LICENSED CONTRACTORS DECLARATION DISTRICT NO PR ESSED BY
I hereby off irm 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 m license is in full force and effect 5 PER SYSTEM tY
FINAL A VALIDATION u
License Numb �Lic. Class ` 3 6 DAT�,f,i'6 ��8'�'�
OC
�w . )/ O
Contractor Dote � 3 ��. A "' 'A"s.+ +„/ V
❑ W
I am exe R d
0.8P.C. for this reason Plan check fee : '
Date:
Signature
/�s�s e')
PLUMBING PERMIT ISSUING FEary J V 4 3 7 91A
•
' tt • e • • • 5
7 � E
Plan check applicant Vis
SINGLE FAMILY - I ' e 1,6 5.0
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License oo e v 0 ELaw for the following reason (Section 7031.5, Business and Address
Professions Code): City Tel. No. Or809 8 3
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section pool7044, 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 represent s'of this County to enter upon the - -.-_ - • . ._ __
above- ntioned p op rty for in purposes. -'
SEE REVERSE FOR EXPLANATORY LANGUAGE
i
SiVoris
ure of Permittee at
Voris
` COUNTY OF LOS ANGELES TEMPLE CITY # 0508 LUMBI GA PE fjl,
DEPARTMENT OF PUBLIC WORKS 97D1 LAS TUNAS P 15M-1-011100012
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGALL ID: -- '— FEES PAID BUILDING ADDRESS:
ON FILE
FEE DESCRIPTION: QUANTITY: UOM: AIIOUNT: MP CA 917803302
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: BALDWIN
18585-007-034 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: B4 LOCALITY: TEMPLE CITY
5i LOW PRS GAS 5 OUTLET 1.00 SYS 16.20
TENANT: TOTAL FEES 43.95 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
11/10/99 UT 05/08/00
OWNER: TEL. NO: INIAL DATE FINAL B'.: CODE:
CASSADY ETHEL E (626) 448-7914-
10021 LA ROSA DR
TEMP 917803302 DESCRIPTION OF WORK
GAS FOR FURNACE CHANGE OUT
APPLICANT: TEL. NO:
CONNOR AIR CONDITIONING (626) 286-3157-
4931 ENCINITA AVE. SPECIAL CONDITIONS:
TEMPLE CITY, CA
PNGELES CO
CONTRACTOR: TEL. N0: �O�j APPROVALS DATE INSPECTOR SIGNATURE
CONNOR AIR CONDITIONING (626) 286-3157-
4931 ENCINITA AVE LIC. NO UNDER SLAB WORK
TEMPLE CITY, CA 91780 403735 C20
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: TEL. NO:
ROUGH PLUMBING
LIC. N0: / 111111'
LGAS PIPING
rr n (� /�} // j�-���/J [� GAS VENT
I}�II II II �11 111/\1 l/ O IRS IIIA \1 HOT WATER HEATER
fill l�J LLL_ ����� V� l/ �:/ ll fJ NJ PLUMBING FIXTURES
i
O O >,Y i,�)i LAWN SPRINKLERS
0
GAS TES
UTILITY COMPANY NOTIFIED
`67.c CCWV
Service Tha
GRAY WATER SYSTEM
REPORT ID: DPR263 ROUTE TO: BS0508