HomeMy Public PortalAbout5313 MCCULLOCH AVE_Plumbing__ •.WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I-hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
Pnsure, or a certificate of Workers'Compensation Insurance, 76A667A
or a certified-, opy Cher of ec 380 . C�.) ,� ��A COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKSPolicy No._St'LLiny /t U10V
❑ Certified copy is hereby furnished. BUILDING q
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESSJA '`
Certified copy.is filed with the county building inspec-
tion epart ent. ' NUMBER FIXTURE OR ITEM @ FEE
}',�-� LocAurr
le-
Date Appli4an) WATER CLOSET 10 ,oev NEAREST
CERTIFICATE-OF EXEMPTION FROM WORKERS' 1. BATJA TUB 5 ov CROSS ST.
COMPENSATION INSURANCE SHOWEROWNER
(This section need not be completed if the work involved by 715T11 - 1611
MAIL
the permit is Vor one hundred dollars($100)or less.) LAVATORY ( @p ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK 76t CITY61W I-)r T O. /
so as to become subject to the Workers'Compensation Laws. DISHWASHER + y�
CONTRACTOR /�♦ ,
Date Applicant CLOTHES WASHER ADDRESS ��
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL.NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. 1 WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. �o PROCESSED BY
I hereby affirm that I am.licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business 7 OUTLETS OVER
and Professions Code and m license is in full force and a ect. I 5 PER SYSTEM
Y FINAL _qz VALIDATION C
License NDATE um
/ FINAL
Contractor Date��� BY C
❑ ~
I am exempt under Sec. W
BAP.C. for this reason ® �^
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$ 1� O
Signature
TOTAL FEE DS 47D
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address AMY°s
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. 33137je�-'°I}I1
❑ I, as owner of the property, will do the work and the j ITEM";
structure is not intended or offered for sale (Section
7044, Business and Professions Code). j 13 f t-L 105.00
CONSTRUCTION LENDING AGENCY CHECK �,i,f�s°0-
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CHANGE °Ijij
(Sec. 3097, Civ. C.).
Lender's Name [)i;001—telrill .V;:1f?
Lender's Address 71-s— .1 +a
I certify that I have read this application and state that the ® +� 1 i� iis°Zv
&be
a i n is correct. gree to complywith all Countynd State law a ulating Plumbing, and hereby
presentatives of his County to enter upon the
oned property fo insp ion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Per i e Date
I
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0504080010/
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FE55 PAID BUILDING ADDRESS:
TR: 47219 LT: 1 UN: 1 5316 MCCULLOCH AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803513
ASSESSORB : NEAREST CROSS STREET: FREER
8573-014-063 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: D3 LOCALITY: TEMPLE CITY, C
47 WATER HEATER(S) 1.00 WTH 16.20
TOTAL FEES 43.95 ISSUED 0 : PROCESSED : P EXPIRES 0 :
04/08/05 JK 10/05/05
OWNER:
5316 MCCULLOCH AV 4fa:: --
TEMP 917803513 QJ!SCRIPTION OF WORK
WATER HEATER CHANGE OUT
APPLICANT:
TEKAWA (310) 515-1311-
17111 S. BROADWAY SPECIAL CONDITIONS:
GARDENA, CA 90248
CONTRACTOR: TEL. N0: APPROVALS DATE INSPECTOR SIGNAT
ACTION CONTRACTORS, INC. (310) 515-1311-
17111 S. BROADWAY LIC. NO UNDER SLAB WORK
GARDENA, CA 91248 652535BC36
TER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT0 TEL. O:
ROUGHG
LIC. NO:
GAS PIPING
GAS VENT
HOT,WATER HEATER
PLEdBING T R S
LAWN SPRINKLERS
S TEST
UnTff C P I
I SYSTEM
i
REPORT ID: DPR263 ROUTE TO: BS0508