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Home My Public Portal About6218 LOMA AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I heresy, affirrwathat I have a certificate of consent to self in- 20-0026 DPW 4/87 n 76A667A `1U' sure,pr a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) certified copy thereof (Sec. 3800, Lab. C.)' Policy No. Company COUNTY OF LOS ANGELES, DEPT. OF PUBLIC WORKS Certified copy is hereby furnished: BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) 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. COMPENSATION INSURANCE SHOWOWNER ER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or.less.) - LAVATORY ADDRESS Me , I certify that in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so CITY TEL. No as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption, you should become subject to the Workers'Compen- sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM CITY TEL. NO: ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION' n DISTRICT NO, PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS-SYSTEM . /OUTLETS ltJ 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER fe d Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION DATE 0.O License Number Lic. Class U FINAL Contractor Date BY O I am exempt under Sec. LU B:&P,C. for this reason Plan check fee Poo. g Date: PLUMBING PERMIT ISSUING FEE$ p p . Signature TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and A Professions Code): Address "s =7 I, as owner of the property, will do the work-and the City Tel. No. -` structure is not intended or offered for sale(Section 7044, i 'TENS 'Business and Professions Code). ► __ t~�¢ 11_! 1L i a --e ff J CONSTRUCTION LENDING AGENCY, I hereby affirm that there is a construction lending agency fort_f<. the performance of the work for which this permit is issued (Sec. 3097, Civ. C). Lender's Name I !31�i 9 ( _-IEjsr 'tvr`?i Lender's Address .- ' . 3 Coir;^'�_'••` 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 authorizer presentatives of this County to enter upon the above-m ioned property ection purposes. �. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERSCOMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76Ab67A � ' insuie, or a certificate of Workers' Compensation Insurdnce, CE 817,(REV. 10/8'1) , or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING El a / �- Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY Date Appligant WATER CLOSET NEAREST a� CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER (This section need not be completed if the work involved by SHOWER ,�9 the permit is for one hundred dollars ($100)or less.) ' LAVATORYMAIL �. I certify that in the performance of the work for which this ADDRESS permit is issued, I shall not employ any person in any manner SINK CITY li A TEL. NO f so as to become subject to the Workers'Compensation Laws. DISHWASHER ,•C v' 7f'!7 ' CONTRACTO Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY TEL. NO. LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM- / OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATIONDATE O License Number Lic. Class FINAL Contractor Date BY I am exempt under Sec. � B.&P.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name S I hereby affirm that I am exempt from the Contractor's Licensec O O c r Law for the following reason (Section 7031.5, Business and Address r .Professions Code): City- Tel. No. -�7 ) '` ° C-19 0 ❑ I, as owner of the property, will do the work and the c !; n f- 07' structure is not intended or offered for sale (Section 7044, Business and Professions Code). ® C, 20 7_ 8 U 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. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the ab ve-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date 76A667 (CE-817)-8-71 f ' 04' APPLI<fATION FOR PLUMBING PER IT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FCCROSSISSST. �D / ��I G2 �� FOR APPLICANT TO FILL IN (PRINT OR TYPE) ) G 0 J,:5.411.1-001C - NUMBER FIXTURE OR ITEM @ FEE WATER CLOSET 1.75 OWNER MAIL BATH TUB 1 75 ADDRESS ,!5�j >— ' SHOWER 1•,75 CITY 1 �f TEL. N0 LAVATORY 1 75 CONTRACTORG SINK 1 .75 ADDRESS A0 DISHWASHER 1.75 CITY , EL. NO. 7� CLOTHES WASHER 1.75 STATE +� rLIC LICENSE NO. �/� �� CLASS SWIMMING POOL RECEPTOR 1.75 TRIC� �PNEJ O. GROUP P OCESSED BY LAWN SPRINKLER SYSTEM 1.75 VV11 - e11 ¢ _ WATER HEATER 1.75 INDUSTRIAL WASTE APPROVAL GAS SYSTEM OUTLETS 1 75 INSPECTION RECORD OUTLETS OVER .30 5 PER SYSTEM - 3 7 18/7Z- Plan check fee See reverse. PLUMBING PERMIT IS U'ING FEE-$ 3 00 TOTAL FEE APPROVALS DATE INSPECTOR'S SIGNATURE Plan check applicant UNDER SLAB WORK Name ROUGH PLUMBING Address GAS PIPING City Tel. No. GAS VENT l HOT WATER HEATER I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING. GAS TEST _ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL P .� FINAL 7 SIGNATURE �" OF PERMITTEE PERMIT VALIDATI CK. M.O. CASH PLAN CHECK VALIDATION CK. M.O. §. H 6 9 0 NsuL.11 4.7Cu COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF -PUBLIC WORKS 9701 LAS TUNAS PL 0508 0709210006 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: ITR: 5904 IT: 268 6218 LOMA AV I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:1 TEMP CA 917801634 1 (ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: LONGDEN I 15384-011-001 101 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 596 GRID: H2 LOCALITY: TEMPLE CITY, Cl 1 107 BATHTUBS/SHOWERS 4.00 FIX 64.80 I 1 (TENANT: 121 HOSE BIBB(S) 2.00 FIX 32.40 (ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: I 145 WATER CLOSET/URINAL 3.00 FIX 48.60 109/21/07 SR 03/19/08 1 151 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20 1 1 (OWNER: TEL. NO: 155 GAS METER (PRIVATE) 1.00 MET 16.20 (FINAL DATE FIUAL BY: CODE: I ICHIN GENNA (626) 580-6238- 1 TOTAL FEES 205.95 I I 16218 LOMA AV 1 1 1 ITEMP 917801634 1 r E CRIPTION OF WORK I I 1PLUMBING FOR ADDITION AND REMODEL 1 1APPLICANT: TEL. NO: I ICHIN (626) 580-6238- I 16218 LOMA AVE. I ISPECIAL CONDITIONS: 1 ITEMPLE CITY CA 91780 I I I I ICONTRACTOR: TEL. NO: I 1APPROVALS DATE INSPECTOR SIGNATURE 1 (AIR CARE MECHANICAL CO. (626) 442-6792- 1 1- 18143 CELITO DR LIC. NO I 1UNDER SLAB WORK I I 1 IROSEMEAD CA 91770 516562 C20 *1 I 1 1 I I IWATER SERVICE I 1 1 I IPLASTIC Y/N METAL Y/N 1 1ARCHITECT OR ENGINEER: TEL. NO: I I 1 ILUK, SAMUEL (626) 858-0438- 1 IROUGH PLUMBING y x 1527 N AZUSA LIC. NO: 1#309 NONE I IGAS PIPING ICOVINA, CA 91722 1 1 I IGAS VENT I 1 I I I IHOT WATER HEATER 1 I I I I IPLUMBING FIXTURES I I I I I I 1 LAWN SPRINKLERS 1 I I I I I I I IGAS TEST I 1 I I I (UTILITY COMPANY NOTIFIEDI I I I I 1 I I I 1CWV I I I I I I I IGRAY 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 I I I I I I I I I I I I I I I I I I* ADDITIONAL DATA ON FILE 1 I I I I I I I IREPORT ID: DPR263 ROUTE TO: BS0508 I I I I I I