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Home My Public Portal About5761 LOMA AVE_Plumbing__ �• KERS'`c20-0026 DPW 4/87 OMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby, alf:im 76A667rthat I have a certificate of consent to self in- 76A667A sure, or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. FOR APPLICANT,TO FILL IN (PRINT OR TYPE) BUILDING r.. Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS" BATH TUB CROSS ST. n COMPENSATION INSURANCE SHOWER OWNER Ala�sr_-_ (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS _ rpVn I certify that in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so CITY ♦. TEL. NO. as to be ome Jublect to the Workers'C mpensatio Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption,you should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR P Y I P CITY TEL. NO. sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER 41 do LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS `/ 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER ) VALI TION and Professions Code, and my 5 PER SYSTEM license is in full force and ef- FINAL tett. DATE7_/ Number Lic. Class U FI C Contractor Date � / g O I am exempt under Sec. � B.&P.C. for this reason � g Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ m j, Signature TOTAL FEE ��) _f—7 2 50 SINGLE FAMILY .330 HOME OWNER-BUILDER DECLARATION Plan check applicant TT MS I hereby affirm that I am exempt from the Contractor's License Name y � � Law for the following reason (Section 7031.5, Business and TOTAL TAL -2>3 m - 8 Professions Code): Address t -1r,• I, as owner of the property, will do the work and the City Tel. No. CHANGE structure is not intended or offered for sale(Section 7044, CHANGEPf��rt Business and Professions Code). CONSTRUCTION LENDING AGENCY tE1111—I1_;i� r t r7 > 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. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby author* a representatives of this County to enter upon the abov entiioned er y f r inspection pur 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 0204080039 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGA D: FEES PAID BUILDINGADDRESS: TR: 12241 LT: 2 5761 LOMA AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802453 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LAS TUNAS 5387-023-002 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY 07 BATHTUBS/SHOWERS 1.00 FIX 16.20 TENANT: 25 LAVATORIES/SINKS 1.00 FIX 16.20 ISSUED N: PROCESSED BY: PAN BY: EXPIRES ON: 45 WATER CLOSET/URINAL 1.00 FIX 16.20 04/08/02 JK 10/05/02 TOTAL FEES 76.35 OWNER: TEL. NO: FIVL DATE FINAL BY: DE: KA YICK TRADING CO INC (626) 286-4210- 8808 MISSION STE201 ROSEMEAD 91770 DESCRIPTION OF WORK C/O KITCHEN SINK, BATHTUB & TOILET APPLICANT: TEL. NO: SAME AS OWNER - __— SPECIAL CONDITIONS: SHU CHEUNG SIU CONTRACTOR: TEL. NO: ��a 6 APPROVALS DATE INSPECTOR SIGNATURE SAME AS OWNER LIC. NO ,�� . \ UNDER SLAB WORK S� WATER SERVICE PLASTIC Y/N METAL Y/N ARCHITECT OR ENGINEER: TEL. N0: ROUGH PLUMBING LIC. N0: GAS PIPING GAS VENT HOT WATER HEATER - - - _ PLUMBING FIXTURES LACI N SPRINKLERS GAS TEST UTILITY COMPANY NOTIFIED CWV, GRAY' WATER SYSTEM REPORT ID: DPR263 ROUTE TO: 8S0508