HomeMy Public PortalAbout10355 LA ROSA DR_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76AM7A
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or ja certified copehg�repo (Sec. 3800,//Lab, C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
�liCy O^O1'7 / ompany G.[•)b J,4_ 1Ak. /�Ty
Certified copy is hereby furnished. 4l11 N1
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date ApplicantWATER CLOSET NEAREST AR
CERTIFICATE OF EXEMPTI FROM WORKERS' BATH TUB ...f'� CROSS ST. R10
COMPENSATIO I SURANCE SHOWER (/�.,!>l/ OWNER , �'
(This section need not be comp ed if the work involved by (J�/ MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY O ADDRESS u
_A1,nAJ6&IiIt Ilk
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner f SINK CITY E q �!_C TEL. NO. Pa
so as.to become subject to the Workers Compensation Lows. ! DISHWASHER O J/7 !L 7
/ CONTRACTOR
Date Applicant - ' CLOTHES WASHER 9 I .//'
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS V,4
Exemption, you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY mow.• 0 TEL. NO.
LAWN SPRINKLER SYSTEM JJ VVJ 02
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. r WATER HEATER �/ LICENSE NO. p� CLASS G
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 ) GAS SYSTEM OUTLETS � t�
(commencing with Section 7000)of Division 3 of the BusinessOUTLETS OVER FF
and Professions Code, and my license is in full force and effect. 1/ 5 PER SYSTEM I.7 FINAL
s� DATE /-�/G7 " VALIDATION u
License Number &0 Lic Class K
FINAL ♦ O
ContractorDate. BY ~
V
W
❑ CL1 a xZempt under Sec N
B.8 .C. for this reason Plan check fee ,
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name z'2 7 9,6 A
I hereby affirm that I am exempt from the Contractor's License Address fj,o o e e e v
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. o,o 7825
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section ► 0 0 0 7 8L2 56
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 06 1 5—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, Ci, 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 10 enter upon the
above moyfr&ped proper r i pection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
C. dot-/I
Sign re of Permittee Date '
COUNTY OF LOS ANGELES TEMPLE CITY n 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0506 1007130011
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
(LEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 37580 LT: 6 1 10355 LA ROSA DR 1
(FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917803402
(ASSESSOR INFORMATION NUMBER I I NEAREST CROSS STREET:
18585-018-049 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY, Cl
163 WATER PIPING BR/FIX 9.00 FIX 60.40 1
TENANT: I TOTAL FEES 88.20 11SSUED ON: PROCESSED BY: PLAN BY: I
107/13/10 SR
IOWNER: TEL. NO: FINAL
/ DATE, FINpL,$Y: CODE:
NAGAZSHI JANE Y - �/(N/�!1/(I✓, �/1
110355 LA ROSA OR
ITEMP 917803402 D±STRIPTIGN OF WORK
I (COPPER RE-PIPE 9 PLUMBING FIXTURES
1APPLICAN T: TEL. N0: I I
IS 0 S PLUMBING (626) 859-0301-
1729 E. ARROW HWY ISPECIAL CONDITIONS: I
IAZUSA, CA 91702 1
I 11 I 11
CONTRACTOR: TEL. NO: 1APPROVALS DATE INSPECTOR SIGNATURE
IS 0 S PLUMBING (626) 859-0301-
1729 E ARROW HIGHWAY LIC. NO UNDFR SLAB WORK
IAZUSA, CA 91702 693502 C36
WATER SERVICE
PLASTIC YIN METAL YIN
(ARCHITECT OR ENGINEER: TEL. NO:
- TROUGH PLUMBING
LIC. NO: tlJ
IGAS PIPING
I I I I I
I IGAS VENT I I
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IHOT WATER HEATER
PLUMBING FIXTURES
(LAWN SPRINKLERS
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IGAS TEST I I I
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I IUTILITY COMPANY NOTIFIEDI I
I I ICw I I I
(GRAY WATER SYSTEM
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1REPORT ID: DPR263 ROUTE TO: 850508 I 1 1 1
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