HomeMy Public PortalAbout10777 LYNROSE ST_Plumbing__ WORKERS'COMPENSATION DECLARATION f1 APPLICATION; FOR PLUMBING;PERMIT
by affirm that I ,have a certificate of consent to self 76A667A
sre, or a ce�tificafe of Workers'Compensation Insurance, I CE 817(REV. 10/81) I
a";.- i�t+fjed:copy'thereof(Sec. 3800; Lab: C.)
11ff(1..��y��� /�� { ; COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NF L RS1t�Company e21JdPJ CEjll�-Tw).
Certified copy is hereby furnished.
FOR.APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING In-T-1
. M
Certified'copy is filed with the county building inspec- ADDRESS
tion department. r �,� D-DA' NUMBER FIXTURE OR ITEM @ FEE
tov�al w 1 LOLOCALITY '�
Wt
/� WATER CLOSET
Date Appli4ant 5 � �\I NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' J BATH TUB CROSS ST. 11�
1 COMPENSATION INSURANCE OWNER SHOWER
(This section need not be completed If the work involved by SHOWER MAIL C
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS F, L
I certify that in the pePformance of the work.for which this
permit is issued,I shall not employ any person in any manner SINK CI TEL.NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER 0
CONTRACT R ) . r�
Date• Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If; -after making this Certificate of
Exemption, you should become subject the Workers' SWIMMING POOL.RECEPTOR z
Compensation:provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY P A ,) g1O5DTEL NO
G
.with comply with such. provisions nor this permit shall be STATE LIC.
deemed revoked. ( WATER HEATER LICENSE NO. Z. Dq
CLASS.
LICENSED CONTRACTORS DECLARATION DISTRICT NOY ESSED BY
I hereby affirm that I am licensed.under provisions of Chapter-9 GAS SYSTEM OUTLETS l/ lam/)
.(.commencing with Section 7000)of Division 3 of the Business OUTLETSOVER
and Professions Code;and my license is in full force and effect. 5 PER SYSTEM :FINAL VALID ION O
DATE V
,L,iLLc.�e�nse'Number ���nJ ` Lic: Class •wU1/ Op
l�baAa seXUlce�9���/, FI Ili-
Contractor
Contractor�RA 15eaYli j l l�ll��)VIG`Date B (�
I.am exempt under Sec.
4
B.&P.C.for this reason z
., Plan check fee
i Date:. . .
PLUMBING PERMIT ISSUING FEE$ o,
� Sigriature - ,n °
j TOTAL FEE ll•. ;26568A
? Plan check applicant
j SINGLE FAMILY # 0,0 0 0 0 5
HOME OWNER-BUILDER DECLARATION Name - 1650
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business.and _
Professions Code): ° ° ° 1 6,5(�c0
❑ ) City Tel:No.
I, as.owner of theproperty,will do the work and.the , 02-2.4-87
structure is not intended or offered for sale ,(Section
I 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 I
(Sec. 3097, Civ. C).
I
Lender's Name
lender's Address
I I certify that I have read this application and state that the 1
above informdtion is correct. I agree to comply with all County ► . !
i ordinances and.State.Laws regulating Plumbing, and hereby 1
I authorize. re resentatives of this County to enter upon the
above-m ned pr rty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
! e
4-�,ate j I'
76A667 - CBB7 7 5/70 '
VAPPL.ICAI'ION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES'
DEPARTMENT OF COUNTY ENGIIOM
BUILDING AND SAFETY DIVISION BUn�NG •'� y`,
JOHN A.LAMBIE. COUNTY ENGINEER
COLEMAN W.JENKINS. SUPT. OF BUILDING LOLL
NSAAEST- /, .
FOR APPLICANT TO FILL IN PR NT.OR.TYPE) CROSS ST. /Q_/.
NUMBER FIXTURE OR ITEM EACH' - _FEE /�- l
a WATER CLOSET 1.50. OWNER 109
MAIL
BATH TUB 1.50
SHOWER 1.50 CITY 67 L.NO
LAVATORY 1':50 CONTRACTOR
SIN$ 1.50 'ADDRESS 137
DISHWASHER .'N
CLOTHES WASHER 1':50 STATE /�� . LIC
LICENSE N CLASS
SWIMMING POOL RECEPTOR 1.50 DISTRICT Nm. GR E. - PR GES D BY
LAWN SPRINKLER SYSTEM 2.00
WATER HEATER 1.50 PPROVAL
INDUSTRIAL,A
GAS•SYSTEM OUTLETS 1.50' INSPECTION RECORD
OUTLETS OVER
5 PER SYSTEM 30
z
Plan check fee 25% of above. See reverse.
PLUMBING PERMIT ISSUING FEE•$ 2 00'
TOTAL FEE
APPROVALS DATE. mBrECTOR•S.SIGNATURE
Plan check applicant UNDER SLARWORK
Name ROUGH PLUMBING
Address GAS PIPING
.GAS VENT
City Tel. No. HOT WATER HEATER a
IN
EREBY ACKNOWLEDGE THAT 1 HAVE,READ THIS APPLICATION - ..
'AND STATE THAT THE, ABOVE 18 CORRECT'AND AGREE TO COMPLY .PLUMBING FIXTURES `
WITH ALL' COUNTY ORDINANCES AND STATE LAWS' REGULATING GAS TEST
PLUMBING. - %i -
1 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 w .•!/
RESIDE IN.THE ABOVE DESCRIBED RESIDENT L PROPERTY. " FINAL g `
SIGNATURE JACK.R.'ALL'EN, SU' a ISING CHAN11CAL EN:G'R.`
OF PERMITTEE r
PERMIT VALIDATION M.O., " CASH
PLAN CHECK VALIDATION CK. M.O. CASH
_ 741 .
76A667A (`C;,E 81719) -477
APPLICATION FOR PLUMBING PERMIT
BUIL 1D NG ND SAFETY D SIGN
r
FOR APPLICANT TO FILL IN(PRINT OR TYPE( ADDR
NUMBER FIXTURE OR ITEM ® FEE ADDRESS
WATER CLOSET LOCALITY
NEAREST
BATH.TUB CROSS ST. 6
SHOWER OWNER'
LAVATORY MAIL pp�� �j
ADDRESS 0. /
'SINK CITY G TEL.NO.
DISHWASHER CONTRACTOR le
^-
CLOTHES WASHER Y '
ADDRESSr
SWIMMING POOL RECEPTOR
CITY W TEL NO. �3
LAWN SPRINKLER SYSTEM
STATE LIC.
WATER HEATER LICENSE NO. C
GAS SYSTEM OUTLETS DISTRICT NO.. GROUP , P SED By
OUTLETS OVER C
5 PER SYSTEM INDUSTRIALQ%
1 WASTE APPROVAL
"• INSPECTION RECORD 61.
er
T
e
Plan check fee
PLUMBING PERMIT ISSUING FEE$
TOTAL FEE --------------
Plan check applicant
Name APPROVALS DATE INSPECTOR'S SIGNATURE
UNDER SLAB.WORK 42
Address ROUGH PLUMBING
City. Tel.No., GAS PIPING
I HEREBY ACKNOWLEDGE THAT.1 HAVE READ THIS APPLICATION AND STATE GAS VENT
THATTHE ABOVE.IS CORRECT AND AGREE TO COMPLY WITH'ALL COUNTY ORDINANCES t
AND STATE LAWS REGULATING PLUMBING. HOT WATER HEATER
•1 HEREBY CERTIFY THAT I-AM PROPERLY REGISTERED AND/OR LICENSED AS PLUMBING FIXTURES -
REOUIRED BY LOS ANGELES COUN AND STATE OF CALIFORNIA OR THAT I AM THE .GAS TEST .
LEGAL OWNER OF.AND INTEN ES16E IN THE ABOV. ESCRIBED RESIDENTIAL ,
PROPERTY. UTILITY CO.NOTIFIED
Z/Z1�l
SIGNATURE.
OF PERMITTEE FINAL
o.f:o
POLICY]HOLDER.
POLICY NUMBER,
• COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0106140005
BUILRING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
" PHONE: (626) 285-0488 EXT:
L S PAID BUILDINGADDRESS:
TR: 24579 LT: 4 10777 LYNROSE ST
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802925 Ai C/`V t v G�
ASS SOR B NEAREST CROSS STREET: Ib�'1 V t
8573-011-012 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRI C3 LOCALITY: TEMPLE CITY
13 DISHWASHER(S) 1.00 FIX 16.20
25 LAVATORIES/SINKS 1.00 FIX 16.20 ISSUED 0PROCESSED P N B P RES 0
51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20 06/14/01 UT 12/11/01
TOTAL FEES 76.35
OWNER: TEL. NO: FINAL DAirE CODE:
BOLANDER RICHARD;KATHRYN (626) 447-7186- (6 I
10777 LYNROSE ST v 0
i
TEMP 917802925 DESCRIPTION OF WO
KITCHEN REMODEL AND H TER REL ATE
T
NEWMAN (626) 285-2602-
9144 SOUTHVIEW SPECIAL CONDITIONS:
SAN GABRIEL
,-�AGELFS do--, -
CONTRACTOR: TEL. 0: APPROVALS DATE INSPECTOR SIGNATURE
NEWMAN, ROBERT (626) 285-2602- %d t
9914 SOUTHVIEW LIC. NO
UNDER S OR
SAN GABRIEL CA 91775 432157 B "•�'
WATER SERVICE ICE
ARCHITECT-OR ENG NEER: TEL. 0: p,' u I-- 1� � '+ PLASTIC Y/N METAL Y/N
f
p—'jr! 1iiiILLLI I lI IiiI
` �IROUGH
i, 0 G PLUMBING
LIC. NO / GAS PIPI
IG
d
- - —— �- -- -- iGAS VENT
?,ys� (�, HOT WATER-HEATER
II r I = �•
- ---- - -- - - ---- ---- -- --�ki
PLUMBING R S
SPRINKLERS
GAS TEST
UTILITY COMPANY NOTIFIED
Service I
--- � � GRAY WATER SYSTEM
REPORT ID: DPR263 ROUTE TO: BS0508