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Home My Public Portal About6103 MUSCATEL AVE_Plumbing__ " ��vWORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT hr eby'affirm,that I have a certificate of ci`-nsent to self 20-0026 DPW 6/S7 a Insure, or a certificdte of Workers'Compe`nsotiondnsutance, 76AS67A or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS ® /t(�S�� Certified copy is filed with the county building inspec- tion department. NUMBER FIXTURE OR ITEM FEE LOCALITY ^� WATER CLOSET Date Appli4anf NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. Q,Q r COMPENSATION INSURANCE SHOWER OWNER L bo(J (This section nood not bo complotod If tho work Involvod by MAIL tho permit Is for ono hundrod dollars(3100)or loss.) LAVATORY ADDRESS i(&f O Ge �L I certify that in the performance of the work for which this , permit is issued, I shall not employ any person in any manner SINKCITY 5A.0 T . NO. $� so as to become subject to the Workers'Compensation Laws. DISHWASHER !� CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM 1 with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION I DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM �, OUTLETS (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER i and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL DATE ZC1 i VALIDATION License Number Lic. Class C3 y FINAL Contractor Date BY ❑ I am exempt under Sec. L V BAP.C. for this reason ®! t v Plan check fee Cn Date: PLUMBING PERMIT ISSUING FEE$ Signature � �Q Plan check applicant TOTAL FEE ' SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name Pj f I hereby affirm that I am exempt from the Contractor's License Address �� ( /Q,(�� Law for followingreason Section 7031.5, Business and Prof ns Code): City �� ! Tel. No. �� _�' I, as owner of the property, will do the work and the structure is not intended or offered for sale (SectionP 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 a d State laws regulating Plumbing, and hereby authorize r e vee of this County to enter upon the above-me coned pro erty for inspection pu Poses SEE REVERSE FOR EXPLANATORY LANGUAGE Signatur o Permittee Dat , WORKERS"COMPENSATION DECLARATION APPU ° TT OH FOR PLUMBING PERMIT 111-hereN Wfirm that I have a certificate of consent to self 76A667A vrrrraa 1� SY®® .r. t! insure,'or 6 certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) or d certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No? q -n companAP-J)Tthl i[' TTldemnity Certified copy is hereby furnished. BUILDING ® FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS � Certified copy is filed with the county build' g inspec- tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY ,� Date 1 8/•Appli4anf 1 WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION M WORKERS' BATH TUB CROSS ST.Garl ba 1 di COMPENSATION INS RANCE OWNER (This section nood not bo complotod if tho work involved by SHOWER , T E tho permit is for one hundred dollars($100)or less.) LAVATORY 6 00 MAIL I certify that in the performance of the work for which this ADDRESS 610'3 NJ-Jc;rat-PJ permit is issued, I shall not employ any person in any manner SINK CIN San Gah-riel TEL. N so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Universal P lamb in Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR 2631 Lee Ave. Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY.S. E1 Monte TEL. NO.with comply with such provisions of this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NQ. OCESSED BY I hereby affirm that 1 am licensed under provisions of Chapter 9 GAS SYSTEM 1 OUTLETS V� U (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER b and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL/�� f �/ VALID IONIL DATELicense Number 396678' Lic. Class sib V contractor[it]Ivercal ?1hmate 12-12-$4 BY ❑ I am exempt under Sec. ` UN 9 L ; 2Z 6 8 B:BP.C. for this reason Plan check fee Dote: PLUMBING PERMIT ISSUING FEE$ I ° ° 3 4 5 0 Signature o 0 0 Q SINGLE FAMILY TOTAL FEE 34 50 3 4 1228-5 50 Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Low for the following reason .(Section 7031.5, Business and Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the 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 PIP authorize represen ti sof this County to enter upon the above-mentio d ro erty f r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 12-12-84 Sign re of1sermittee VDate COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1209120011 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: ILEGAL ID: I FEES PAID I BUILDING ADDRESS: 1 ITR: 5903 LT: 51 I 1 6103 MUSCATEL AV I I FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( TEMP CA 91780 I (ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: 1 15386-009-046 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 596 GRID: G2 LOCALITY: TEMPLE CITY, Cl I 107 BATHTUBS/SHOWERS 3.00 FIX 48.60 I 1 (TENANT: 25 LAVATORIES/SINKS 4.00 FIX 64.80 (ISSUED ON: PROCESSED BY: PLAN BY: I 1 45 WATER CLOSET/URINAL 3.00 FIX 48.60 109/12/12 SR 1 I TOTAL FEES 189.80 1 (OWNER: TEL. NO: I IFI AL DATE FINAL Y: CODE: [WONG, DAVID (972) 623-7820- I I 16103 MUSCATEL AVE I I I ITEMPLE CITY CA 91780 1I IDESCRIPTION OR WORK 1 1 IPLUMBING FOR KITCHEN AND 3 THROOMS REMODEL 1 I I I [APPLICANT: TEL. NO: I I I [SAME AS OWNER [ I ISPECIAL CONDITIONS: I I I I I I I I I I I I I [CONTRACTOR: TEL. NO: 1 (APPROVALS DATE INSPECTOR SIGNATURE 1 [SAME AS OWNER - I I I LIC. NO i JUNDER SLAB WORK I I I I IWATER SERVICE I [ I (PLASTIC Y/N METAL Y/N (ARCHITECT OR ENGINEER: TEL. NO: I I I I I I - I IRDUGH PLUMBING 1 LIC. N0: 1 I I I IGAS PIPING IGAS VENT I I I I I I I I I I I IHOT WATER HEATER I I I I I I I I (PLUMBING FIXTURES I I I I I I I I (LAWN SPRINKLERS I I I I I I I I I I I IGAS TEST I I I I I I 1-1 I (UTILITY COMPANY NOTIFIED( I I ICWV -1-1 I I [ IGRAY WATER SYSTEM 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 I I I I I I I I