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HomeMy Public PortalAbout5756 LOMA AVE_Plumbing__ W} OktERS'COMPENSATION DECLARATION APPLICATION FOR P` IN .PER �/,IT h}�ec' .pffiiti, that I have a certificate of consent to self 76A667A IM �irave, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof (Sec.S 3800, L'ob..C. COUNTY OF'LOS ANGELES BUILDING AND SAFETY Policy No&tZ_� 'Company Certified copy.is hereby,furnished. 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 a FEE LOCALITY • WATER CLOSET r G Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE, SHOWER ,�. OwrvER. f /�7U, (This section need not be completed if the work involved by 14 the permit is for one hundred dollars $100 or less. MAIL' p ( ) ) LAVATORY ADDRESS I certify;that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK �• CITY TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the` Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code; you must forth- LAWN SPRINKLER SYSTEM CITYa Y • TEL. NO. A with comply with such provisions'or this permit shall be STATE LIC deemed revoked. WATER HEATER LICENSE NO. CLASS .6 LICENSED CONTRACTORS DECLARATION DISTRICT NO. R CESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS S U SU( (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER > and Professions Code, and my license is in full force and effect. 5 PER SYSTEMA. A. p� VALIDA DN v DATE License-Number� �•S --� Lic. Class p� /� �/�/ FINA O Contractor ! fI--� /a�niaez Date � BY V ❑ 06 I am exempt under Sec. B.&P.C. for this reason 1 O b A 4 Plan check fee Date: ##.ao ® o.o5 Signature PLUMBING PERMIT ISSUING FEE$- it 015-0 • TOTAL FEEv I © a 4 5,0 Plan check applicant SINGLE FAMILY _ o o • 3 4,5 0 3 HOME OWNER-BUILDER DECLARATION ' Name' I 1 O 9_$4 I hereby affirm that l am exempt from the Contractor's License gddress ' Law for the following reason (Section 7031,5, Business and Professions Code): City Tel. No. ❑ I, as owner of the property, will do.the work and the structure is not intended or offered for sale (Section .' 7044, 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. l 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 property for inspection purposes.;f SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date ' COUNTY OF LOS ANGELES TEMPLE"CITY ,# 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1207170003 BUILDING AND .SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 " „ PHONE: (626) 285-0488. EXT: ILEGAL ID: 1 FEES PAID. ' BUILDING ADDRESS: 1 I ON FILE 1 5756 LOMA AV 1 1 IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA 917802452 1 (ASSESSOR INFORMATION NUMBER: I , I " NEAREST CROSS STREET: 1 15387-017-017 - 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY CAI 1 - 125 LAVATORIES/SINKS 2.00 FIX, 32.40 1 1 (TENANT: I TOTAL FEES 60.20 (ISSUED ON: PROCESSED BY: PLAN BY: 1 1 107/17/12 SR 10WNER: TEL. NO: 1 IFINAL DATE FINAL"BY: CODE: IHERMOSILLO, SUSAN (626).485-5845- 15756 626) 485-5845-15756 LOMA AV - 1 ITEMP 917802452 I - 1DESCRIPTION OF WORK. 1 .. 1 (REPLACE 2 BATHROOMS LAVATORIES ONLY I (APPLICANT: TEL. NO: I ISAME AS OWNER I I ISPECIAL CONDITIONS: ICONTRACTOR: TEL. NO: IAPPROVALS - � DATE INSPECTOR SIGNATURE ISAME-AS OWNER - I LIC. NO I (UNDER SLAB WORK I I I 1 IWATER SERVICE IPLASTIC Y/N METAL Y/N 1ARCHITECT OR ENGINEER: TEL. NO: I - IROUGH PLUMBING LIC. NO: I (GAS PIPING - E IGAS VENTI EXPIRD IHOT WATER HEATER 1 1 I I I I IPLUMEING FIXTURES 1 I ILAWN SPRINKLERS 1 1 I I I I I I IGAS TEST (UTILITY COMPANY NOTIFIEDI I I I I 1CWV 1 I I,GRAY WATER SYSTEM I•. . ' • 1 _ I I I I I I I I I I 1 IREPORTID: DPR263 ROUTE TO: BS0508 I I I I I I