HomeMy Public PortalAbout10167 LOWER AZUSA RD_Plumbing__ w/Of2KERS'.COMPENSATION DECLARATION APPLICATION FOR PLUMBING -PERMIT
l;hereb sa irm thai i have a-certiicate oconsent to self in- 120-0026 DPW 4/87 n
1 Y.% fff( 76A667A
sura _ond certificate of Workers'Compensation Insurance,ora ,CE 817(REV. 8/86)
certified copy•thereof (Sec. 3800, Lab.
Policy,No. mpanY
CC!! COUNTY OF LOS ANGELES DEPT: OF=PUBLICIWORkS•
7o7Coc
. Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN (PRINT OR TYPE) ./�
Iertified copy is filed with the county building inspection ADDRESS <
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER'CLOSET(TOILET) VQ
Datey App i NEAREST_
CERTIFICATE OF EXEM ON FROM WORKERS' BATH TUB 12,
JO
CROSS ST. ,
COMPENSATION INSURANCE SHOWER w OWNER '000bL��x.
(This section need not be completed if the work involved by V MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY. d� ADDRESS ��PZ
I.certify that'in the performance of'the.workfcir which this per- '
mit is•'issued4'I shall not employ any person:in any manner so SINK 6 CITY a?1__ TEL. NO.
as to.become subject to the Workers'Compensation Laws. DISHWASHER U
CONTRACTOR �►-y/p i.2
Date Applicant CLOTHES.WASHER '-CJ-[T
NOTICE TO APPLICANT.,If, after making this Certificate'of Ex= ADDRESS
SWIMMING POOL RECEPTOR ,?
emption,:you should become subject,to the Workers'ti dmpen- CITY �L�IJQ�i$�- TEL NO.?/l/- 3
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or:this permit shall beideemed revok- STATE �r�p�/ UC: I
ed: WATER HEATER LICENSE NO. �J ! ! CLASS
LICENSED'CONTRACTORS DECLARATION �J DISTRICT NO. -/ PROCESSED BY
I hereby affirm that-I am licensed under provisions of Chapter ` GAS SYSTEM � OUTLETS16
�1(/
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER (J 0
and'Professions Code, and my License is in full force and ef- 5 PER SYSTEM FINAL V I ATION
feet. DATE "'
License-Number �jC' Lic. Class
U
FINA
Contract _Date0 9 5; A
`I-am exempt under Sec. # o o-o 0 0 5 W
CL
B.&P.C� for this reason7 .1 - Pjan check fee' - ► ( 0 °.9 4.5 0
Date: PLUMBING PERMIT ISSUING FEE $'
Signature0 0 0 9 iL 5 0.0
TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan cheek applicant "( Q .9-8
t hereby affirm that I am exempt from the Contractor's,License Name
Law=for the following reason (Section.7031.5, Business and.
Professions Code): Address
El 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. Poo.
I hereby affirm that there is a construction,lending agency for
the performance of the work for which.this permit'is issued -
(Sec. 3097, Ci v;.G.
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
T o ize• representativ of this County to enter Upon the
abov entioned ro for inspection purposes.
��y':ks
SEE REVERSE FOR EXPLANATORY LANGUAGE
g a ure of Perm it-teEV Date
- 'COUNTY OF LOS ANGELES - TEMPLE CITY # 0508 -" PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0506130028
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 45892 LT: 1 UN: 7 10167 LOWER AZUSA RD
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917804000
ASSESSOR INFORMATION NUMBER: - NEAREST CROSS STREET: BALDWIN
8585-012-047 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: B5 LOCALITY: TEMPLE CITY, C
25 LAVATORIES/SINKS 1.00 FIX 16.20
TENANT: 45 '''„T.,.,-"'.,..LTi".,r""_ 1.00 FIX 16.20 ISSUED ON: ' PROCESSED BY: PLAN BY: EXPIRES ON:
i�r �CG fi TOTAL FEES 60.15 06/13/05 JK 12/10/05
OWNER: TEL. NO: FIN��/AAL DATE FINAL BY: CODE:
HOAC, NHI (626) 579-6352-
10167 LOWER AZUSA RD -
TEMP 917804000 D CRIPTION OF WORK
WATER HEATER CHANGE OUT AND LAVATORIE
APPLICANT: TEL. NO:
SAME AS OWNER -
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER -
LIC. NO UNDER SLAB WORK
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: - TEL. NO:
ROUGH PLUMBING
-
LIC. NO:
GAS PIPING
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES
LAWN SPRINKLERS
GAS TEST
UTILITY COMPANY NOTIFIED
CWV
GRAY WATER SYSTEM
REPORT ID: DPR263 ROUTE TO: BS0508