HomeMy Public PortalAbout10345 LA ROSA DR_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I hove a certificate of consent to self 76A667A
insure, or a certificate of Workers' Compensation Insurance, CE 817 (REV. 10/81)
ora certified copy thereof Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Certified copy is hereby furnished. C
FOR APPLICANT TO FILL IN(PRINT OR TYPE) _ BUILDING
Certified copy is filed with the county building inspeo- ADDRESS ROSA
tion� ly-R3 Appli4ant department. NUMBER FIXTURE OR ITEM Cu FEE LOCALITY
r WATER CLOSET k
Dote NEAREST
CERTIFICATE OF EXEMPTIO OM WORKERS' BATH TUB O CROSS ST. H
COMPENSATION I S RANCE SHOWER OWNER FAIA AV Q
(This section need not be complet if the work involved by QaMAIL /
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS K
I certify that in the performance of the work for which this 1 n
permit is issued, I shall not employ any person in any manner SINK CITY J�L TEL. NO. J7
so as to become subject to the Workers Compensation Laws. ' DISHWASHER DD
CONTRACTOR
Date Applicant , CLOTHES WASHER O ADDRESS 1
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY ^-' TEL. NO../s•�]
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM [.� `"
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. ' WATER HEATER LICENSE NO. Q CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO, P ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL �® VALIDATION V
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License Number 39!5 Lic. Class �{LL - pe
FINAL // O
s y— BY �rJ- B'"'" 1-
ContracDate tor W
❑ a I a xempt under Sec. N
8.8 .C. for this reason Plan check fee Z►
Date: PLUMBING PERMIT ISSUING FEE$ U
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name 2 7 9, S R
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and #, o e o o e 5
Professions Code): City Tel. No.
❑ 1, as owner of the property, will do the work and the c`' u a 7 a 2 5
structure is not intended or offered for sale (Section
7044, Business and Professions Code). .0 , 0792560
CONSTRUCTION LENDING AGENCY 0 6 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 laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentionedpra ert for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ure of Permire eDate
- COUNTY Oy LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0811180003
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
(LEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 39580 IT 5 10345 LA ROSA DR
IEEE DESCRIPTION: QUANTITY: DOM: AMOUNT: 1 TEMP CA 917803402
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: ARDEN
8585-018-046 101 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID. C4 LOCALITY: TEMPLE CITY, Cl
1 113 DISHWASHER(S) 1.00 FIX 16.20
(TENANT: 125 LAVATORIES/SINKS 1.00 FIX 16.20 11SSUED ON. PROCESSED BY: PLAN BY: EXPIRES ON:
151 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20 111/18/08 SR 05/17/09
1 TOTAL FEES 76.35 1
OWNER: TEL. NO I (NAL DATE FINAL BY: CODE:
YUHUEI TANG, THOMAS TRUONG- (626) 452-9093- AlTE FINAL
110345 LA ROAS DR. /� 1 I
ITEMPLE CITY CA 91780 I lDftSCFCIPTION OF WORK q1
I IPL EMS ING FOR KITCHEN REMODEL
APPLICANT: TEL, NO:
IWENHUA CHIP (626) 926-4016-
16448 OAK AVE. 1SPECIAL CONDITIONS: 1
ITEMPLE CITY CA 91780 1 1 1
-1
(CONTRACTOR: TEL. NO: I JAPPROVALS DATE INSPECTOR SIGNATURE
SUNYUAN SUPPLY INC. (626) 926-4016- 1 1
16448 OAK AVENUE LIC. NO I (UNDER SLAB WORK
ITEMPLE CITY, CA 91780 799540 C10
(WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: TEL. NO:
I IROUGH PLUMBING
LIC. NO:
GAS PIPING
I IGAS VENT
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I I IHOT WATER HEATER
I I I
I PLUMBING FIXTURES
1 I 1LAWN SPRINKLERS 1 1 1
CAS TEST
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I I (UTILITY COMPANY NOTIFIED( I
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(GRAY WATER SYSTEM
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I IIREPORT ID: DPR263 ROUTE TO: DS0508 1
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