HomeMy Public PortalAbout10157 LOWER AZUSA RD_Plumbing__ r ,WORKERS' COMPENSATION DECLARATION 6 DPW 4/87
76A66APPLICATION FOR PLUMBING PERMIT
76A66
' L hereby,'�Sffirm that'I'have a certificate of consent to self in- 7A
sure,j or a cehificate•of Workers'Compensation Insurance,or a. CE 817(REV. 8/86)
certified copy thereof (Sec. 3800, Lab. -
!, COUNTY OF LOS ANGELES DEPT.,'OF PUBLIC WORKS
Policy Na` 79i'—'FT� Company
Certified copy is hereby furnished. " BUILDING
E
FOR APPLICANT TO FILL IN(PRINT OR TYPE) /Q/� s - �`
Certified copy is filed with t " c unty building inspection ADDRESS J
u. department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date% �/ WATER CLOSET(TOILET)
G F�� Appli nt It ITONEAREST
BATH TUB. /► CROSS ST.
CERTIFICATE OF EXEM N FROM WORKERS' V
COMPENSATION INSURANCE SHOWER OWNER
(This section need not•be completed if the work involved by !f MAIL
the permit is for one hundred dollars-($100)or less:) LAVATORY V O ADDRESS �lo Z
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall-not employ any person-in any manner so CITY TEL. NO.
as to become subjectJorthe Workers' Compensation Laws. DISHWASHER
V
(//� CONTRACTOR &W i d/
Date Applicant CLOTHES WASHER 6 ADDRESS C�(� G C7C��a�
NOTICE TO APPLICANT: If, after making this Certificate,of Ex- L / �•
, should become subject to the WorkersCom en- SWIMMING POOL RECEPTOR
emtionbj '
you ✓
P Y I P CITY TEL. NO.�L�3337
cation provisions of the Labor Code, you must forthwith camp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. / WATER HEATER 0LICENSE NO. �' CLASS
LICENSED CONTRACTORS DECLARATIONGAS SYSTEM OUTLETS r1 DISTRICT NO. PR ESSED BY
I hereby affirm that I am Licensed under provisions of Chapter / ( G�
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and m license is in full force and ef- 5 PER SYSTEM
fect. my
2 DATEL ��� VALI ATION
License Number L Lic. Class -63 O
FINA U
Contract�75`) M /Ge, Date BY
O
a
I am exempt under Sec.
U
�0,95.0A
B.&P.C. for this reason ► (A-
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ # o 0 0.o 0 5
Signature TOTAL FEE .1 o - 91k5 0
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant o 10 094,5035-
I
9 4,5 0 35
v-
I hereby affirm that I am exempt from the Contractor's License Name.
Law for the following reason (Section.7031:5, Business and ( 0,.198 8
Professions Code): Address
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,
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. I agree to comply with all County , -
ordinances and State laws regulating Plumbing, and hereby
ze representatives of this County to enter upon the
above- entione r erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ature of Permitt Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0901060021
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS: . I
ITR: 45892 LT: 1 UN: 2 10157 LOWER AZUSA RD I
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917804000 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
18585-012-042 101 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 597 GRID: B5 LOCALITY: TEMPLE CITY, Cl
147 WATER HEATER(S) 1.00 WTH 16.20
(TENANT: I TOTAL FEES 43.95 (ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
101/06/09 SR 07/05/09 I
TOWNER: TEL. N0: T 1 1
FINALEEREIT BY: CODE:
1ICHANG10157 LOUISE110157 LOWER AZUSA RD 1
ITEMP 917804000 1 IDESCRIPTION OF WORK 1
IREMOVE/REPLACE GAS WATER HEATER 1
I
(APPLICANT: TEL. NO:
IHOME DEPOT (800) 454-8955- I
112601 132ND. AVE NE I ISPECIAL CONDITIONS:
1KIRKLAND, WA 98034 I 1
I I
(CONTRACTOR: TEL NO: 1 (APPROVALS DATE INSPECTOR SIGNATURE I
IHOME DEPOT (800) 454-8995- I
112601 132ND AVE NE LIC. NO I (UNDER SLAB WORK I I I
IKIRKLAND WA 98034 602331 I 1 I I I
IWATER SERVICE I I I
IPLASTIC Y/N METAL Y/N I 1 1
1ARCHITECT OR ENGINEER: TEL. NO: I I I I
IROUGH PLUMBING I I I
LIC. NO: I I- I I I
IGAS PIPING
I I
1 1 IGAS VENT T
IHOT WATER HEATER 1
I
IPLUMBING FIXTURES I I
1 1 ILAWN SPRINKLERS I I
I I 1 I
I I
1GAS TEST I I
IUTIL•ITY COMPANY NOTIFIEDI I I
1 1 CWV
IGRAY WATER SYSTEM I I
I I I I I I
1 I I I I I
I I I I I I
I I I I I I
I I I I I I
I IREPORT ID: DPR263 ROUTE TO: BS0508
I I
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0710300006
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 45892 LT: 1 UN: 2 1 10157 LOWER AZUSA RD
IFEE DESCRIPTION: QUANTITY: DOM: AMOUNT: ( TEMP CA 917804000
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
18585-012-042 101 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 597 GRID: B5 LOCALITY: TEMPLE CITY, Cl
145 WATER CLOSET/URINAL 1.00 FIX 16.20 I
(TENANT: I TOTAL FEES 43.95 11SSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
I 110/30/07 SR 04/27/08
1OWNER: TEL. NO: IFINAL V DAT BY: CODE:
ILOUISE CHANG (626) 689-5899- I 1 /���
110157 LOWER AZUSA RD I 1 /w 1
1TEMP 917804000 1 IDESCRIPTION OF WORK 1
I 1 IREPLACE HOT WATER HEATER 1
I 1 I I
(APPLICANT: TEL. NO: I I I
1PLUMB-IN-TIME (866) 293-3031- I 1 1
ISPECIAL CONDITIONS: I
I I
1 TEL. NO: 1 IAPPPOVALS DATE INSPECTOR SIGNATURE I
(CONTRACTOR: I
(PLUMB-IN-TIME PLUMBING SERVICES INC (866) 293-3031-1041 1 1
1360 MEMORIAL DR #140 LIC. NO 1 (UNDER SLAB WORK 1 1 1
ICRYSTAL LAKE, IL 60014 B/L564192 * 1 11 1 1
I I 1WATER SERVICE
I I (PLASTIC YIN METAL YIN 1 1 1
(ARCHITECT OR ENGINEER: TEL. NO: I I 1 1 1
IROUGH PLUMBING 1 1 1
1 LIC. NO: I I I I
IGAS PIPING I 1
1 1 (GAS VENT I 1 1
IHOT WATER HEATER 1 I I
IPLUM13ING FIXTURES 1 1 1
I I I I
I I (LAWN SPRINKLERS 1 1 1
1 1 IGAS TEST 1 1 1
1 1UTLITY COMPANY NOTIFIEDI I 1
1 I 1CWV I I I
(GRAY WATER SYSTEM 1 1 I
1 I i I I I
1 I I I I I
1 I I I I I
I* ADDITIONAL DATA ON FILE 1 1 1 1
I (REPORT ID: DPR263 ROUTE TO: BS0508 1 1 1 1
I I I I I I