HomeMy Public PortalAbout5749 OAK AVE_Plumbing__ ` � r
WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I herebyroff vm thbt I have a certificate of consent to self 76A667A
insure or a certificate of'Workers Compensation Insurance CE 817(REV 10/81)
or a cern!ed copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NQ Ji&W.."65 t�ompany I,-
❑ Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the co ty building mspec- ADDRESS /�•
tion department NUMBER FIXTURE OR ITEM
® FEE LOCALITY
Date Applica WATER CLOSET NEAREST
CE TIF CATE OF EXEM I FROM WO ERS' BATH TUB CROSS ST
COMPENSATI INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY *7_9TEL NO,2f
so as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of Z010 /4
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL NO 5 //
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM
deemed revoked STATE LIC
WATER HEATER /LB LICENSE NO 3S� CLASS
LICENSED CONTRACTORS DECLARATION f/ DISTRICT NQ D BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM / OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER r
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL VALIDA N d
License Number Lic Class DATE V
FINAL
Contractor ✓ ate '0 BY 0
❑ I am exempt under Sec d I
B 8P C for this reason NPlan check fee Z i
Date PLUMBING PERMIT ISSUING FEE$ v
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name ;@334.5A
I hereby affirm that I am exempt from the Contractor s License Address
Low for the following reason (Section 7031 5 Business and # e s e Jr
Professions Code) City Tel No
❑ I as owner of the property will do the work and the 1 4250
structure is not intended or offered for sale (Section
7044 Business and Professions Code) , p 42505
CONSTRUCTION LENDING AGENCY I G30-85
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 andAr,
laws regulating Plumbing and hereby
authorize repretomes of this County to enter upon the
above- tionperty for inspection purpose
SEE REVERSE FOR EXPLANATORY LANGUAGE
s
Sign Permittee Dat
• COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1110240011
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
ILEGAL ID FEES PAID I BUILDING ADDRESS 1
ITR 6561 LT 733 I [ 5749 OAK AV 1
I IFEE DESCRIPTION QUANTITY UOM AMOUNT I TEMP CA 917802431 1
[ASSESSOR INFORMATION NUMBER I I NEAREST CROSS STREET 1
18587-005-011 101 PERMIT ISSUANCE FEE 27 80 I THOMAS PAGE 596 GRID J3 LOCALITY TEMPLE CITY Cl
107 BATHTUBS/SHOWERS 2 00 FIX 32 50 I I
ITENANT 125 LAVATORIES/SINKS 1 00 FIX 16 30 ISSUED ON PROCESSED BY PLAN BY [
I 145 WATER CLOSET/URINAL 1 00 FIX 16 30 110/24/11 SR 1
I TOTAL FEES 92 90 1 I
(OWNER TEL NO I IFINAL DATE FINAL BY CODE I
1DANG, ANDREW (626) 285-9091- [ 1 I
15749 OAK AV [ I [
(TEMP 917802431 1 IDESCRIPTION OF WORK 1
I [ IPLUMBING FOR BATHROOM REMODEL I
(APPLICANT TEL NO [ I I
IGLYCHER, ELINOR (800) 418-7055- I [ I
I I ISPECLAL CONDITIONS 1
I I I I
(CONTRACTOR TEL NO [ [APPROVALS DATE INSPECTOR SIGNATURE [
ICALIFORNIA PREFERRED BUILDERS (800) 418-7055- [ 1 I
120335 VENTURA BLVD # 422 LIC NO [UNDER SLAB FORK [ 1 I
IWOODLAND HILLS CA 91364 929364B * 1 I [ I I
[ 1 IWATER SERVICE [ I I
I 1 IPLASTIC Y/N METAL Y/N I I I
(ARCHITECT OR ENGINEER TEL NO I I I I I
- I (ROUGH PLUMBING �[ [
1 LIC NO
IGAS PIPING
IGAS VENT I I I
[ 1 IHOT WATER HEATER I [ I
I 1PLUMBING FIXTURES I I
I (LAWN SPRINKLERS I I I
[ I IGAS TEST I 1 1
p 'fit, I I I
1UTILITY COMPANY NOTIFIED[ I I
ICWV I I I
I GRAY TER SYSTEMWA
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I I I I I I
I I I I I f
1* ADDITIONAL DATA ON FILE [ I [ 1
REPORT ID DPR263 ROUTE TO BS0508
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