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HomeMy Public PortalAbout10310 LA ROSA DR_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm shot I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a cerIf d copy thereof (Sec 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Qi DD-OS/�p� Ll�R4�lSA�� y Ocy o 9P nY L�'#'�8 /0320 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the count buildin insp c- ADDRESS tion department.� NUMBER FIXTURE OR ITEM @ FEE LOCALITY��y',a 3 WATER CLOSET Date Applicant NEAREST CERTIFICATE OF EXEMPTIOryfPOM WORKERS' BATHTUB CROSS ST. COMPENSATION IrSPRANCE SHOWER OWNER (This section need not be comploW if the work involved by O� C/ MAR the permit is for one hundred dollars ($100)or less.) LAVATORY $ ADDRESS 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 V CITY L TEL. NO. so as to become subject to the Workers Compensation Laws, DISHWASHER �• Q� CONTRACTOR Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR ADDRESS Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- CITY TEL. NO. LAWN SPRINKLER SYSTEM So with comply with such provisions or this permit shall 6e STATE LIC. Q deemed revoked. WATER HEATERO LICENSE NO. CLASS L3 LICENSED CONTRACTORS DECLARATION DISTRICT NO, OCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS OD (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER © 0. and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION O License Number �s �/' DATE /� —�'� U Lic. Class vim« s FINAL V ContracJr,lot Date _ds BY U / e U W ❑ us I under Sec. CLNBor this reason , Z Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name a. 2 8 0.8 A I hereby affirm that I am exempt from the Contractor's License Address Low for the following reason (Section 7031.5, Business and ^4 n nu o 0 5 Professions Code): City Tel. No. ' ❑ 1, as owner of the property, will do the work and the y ' - 9625 structure is not intended or offered for sale Section , n/25csi 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 66 15-83 1 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 lows regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mens' ned proper r ' spectton purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE r Sign re of Permittee ate COUNTY OF LOS ANGELES TEMPLE CITY $ 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1312030008 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: ITR: 37580 LT: 18 1 10310 LA ROSA DR 1 (FEE DESCRIPTION: QUANTITY: DOM: AMOUNT: 1 TEMP CA 917803401 (ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: ARDEN 1 18585-018-081 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: B4 LOCALITY: TEMPLE CITY CAI 151 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20 1 (TENANT: I TOTAL FEES 44.00 11SSUED ON: PROCESSED BY: PLAN BY: I 112/03/13 SR I I I (OWNER: TEL. NO: IFINAL DATE FIN L BY: CODE: I 110310SCAULAN, SHELLY (626) 833-4447- /u� 110310 LA ROSA DR ✓ l` (TEMP 917803401 1 IDESCRIPTION OP' WORK 1 RUN 1 GAS LINE TO FAU IN ATTIC (APPLICANT: TEL. NO: I I I ZAPATTA, JOHN (323) 627-3132- PO BOX 9368 ISPECIAL CONDITIONS: ALTA LAMA CA 91701 I I 1CONTRACTOR: TEL. NO: I 1APPROVALS DATE INSPECTOR SIGNATURE 1 IZABATTA HEATING AND AIR CONDITION (909) 989-9200- 1 IPO BOX 9368 LIC. NO 1UNDER SLAB WORK 1 1 ALTA LOMA CA 91701 561159 IWATER SERVICE I I PLASTIC YIN METAL YIN I (ARCHITECT OR ENGINEER: TEL. NO: IROUGH PLUMBING LIC. NO: I IGAS PIPING I I I I I I 1cAs VENT I I I I IHOT WATER HEATER I IPLUMB ING FIXTURES 1 1 (LAWN SPRINKLERS 1 1 I I I I I (GAS BEST I I I 1 11 1 (UTILITY COMPANY NOTIFIEDI I I I I Icwv I I I I (GRAY WATER SYSTEM 1 I I I I 11 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I 11 I I I I * ADDITIONAL DATA ON FILE I I I I I I 1REPORT ID: DPR263 ROUTE TO: HS0508 1 1 I 1 I I I I I I