HomeMy Public PortalAbout10315 LA ROSA DR_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT.
I hereby affirm that I have a certificate of consent to self 76gyy7A
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
PLO.,
certified<o ther of (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
aOI nnoI o0?1 1�i OW
ALA—cy No. Company Wl91.t.] LL `l,� n o
Certified copy is hereby furnished. O^
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the count building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY q
Date (Q1J!V-VQZApplicant 7 WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION M WORKERS' BATH TUB CROSS ST.
COMPENSATION I S�lf
ANCE SHOWER OWNER k/�� /$t/
(This section need not be comF he work involved by MAIL A
the permit is for one hundred dollars ($100)or less.) LAVATORY D ADDRESS 5 /c
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL NO.
so as to become subject to the Workers Compensation Lows. DISHWASHER W0 M
CONTRACTOR 6 /
Date Applicant CLOTHES WASHER 00 ADDRESS /
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL'RECEPTOR O
Exemption, you should become subject to the Workers' CITYTEL. NO. O
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM � (r ".— pair ,1
with comply with such provisions or this permit shall be STATELIC.
deemed revoked. WATER HEATER (�Y� LICENSE NO. !3900 CLASS
LICENSED CONTRACTORS DECLARATION _^ DISTRICT o. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEMto of
OUTLETS V
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER d
and Professions Code,andmylicense is in full forceandeffect. 5 PER SYSTEM FFIIAN EL _ VALIDATION V
License Number 39, 9I&o Lic. Class- :All �
p FINAL O
Contractor Dale �y-e3 BY -Q-!
❑ W
i am empt under Sec s-
N
B.&P. . for this reason , ?
Plan check fee '
Date: PLUMBING PERMIT ISSUING FEE$ 0
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name 't'�,� 9 2 Q
I hereby affirm that I am exempt from the Contractor's license Address
Low for the following reason (Section 7031.5, Business and
oa . ae,5
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the ! e a 7925
structure is not intended or offered for sale (Section
7044, Business and Professions Code) pool 78 2 5 u
CONSTRUCTION LENDING AGENCY 0'6. 15_8 3
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 laws regulating Plumbing, and hereby .
authorize representatives of this County to enter upon the
above-mentioned p�ee
pection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Lk
Signa re o Permit Date
COUNTY OF LOS ANGELES TEMPLE CITY g 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0910150008
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
(LEGAL ID: 1 FEES PAID BUILDING ADDRESS:
ITR: 37580 IT: 2 10315 LA ROSA DR
IEEE DESCRIPTION: QUANTITY: UQM: AMOUNT: ( TEMP CA 917803402
(ASSESSOR INFORMATION NUMBER: 1NEAREST CROSS STREET: ARDEN
18585-018-042 101 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: 84 LOCALITY: TEMPLE CITY, Cl
1 147 WATER HEATERS) 1.00 WTH 16.20 1 1
(TENANT: I TOTAL FEES 43.95 11SSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
110/15/09 SR 10/15/10
(OWNER: TEL NO: FINAL DATE FINAL BY CODE:
CHIMAN, YUE (626) 350-1967-
110315 LA ROSA DR
ITEMP 917803402 IDESCRIPTION OF WORK
REPLACE 40 GALLON GAS WATER HEATER SAME LOCATION GARAGE
(APPLICANT: TEL. NO:
ILITTLEFIELD (661) 259-7131- 1 1 1
124663 RAILROAD AVE I ISPECIAL CONDITIONS:
NEWHALL, CA 91321
I I I I
1CONTRACTOR: TEL. N0: 1 (APPROVALS DATE INSPECTOR SIGNATURE 1
AFFORDABLE WATER HEATERS (661) 259-7131-
124663 RAILROAD AVE LIC. NO (UNDER SLAB WORK
INEWHALL CA 91321 627368 C36
I (WATER SERVICE -
PLASTIC YIN METAL Y/N I
(ARCHITECT OR ENGINEER: TEL. NO: I
- IROUGH PLUMBING
LIC. NO: I
IGAS PIPING
I 1GAS VENT I I I
1 1 (HOT WATER HEATER 1 1 1
I
PLUMBING FIXTURES
I I (LAWN SPRINKLERS
I I I
GAB TEST
1 11 1
1UTILITY COMPANY NOTIFIEDI I I
I
I IGWv I I I
I I EYPIRE® GRAY WATER SYSTEM 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
REPORT ID: DPR263 ROUTE T0: BS 0508
I