HomeMy Public PortalAbout6610 OAK AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION
F®® PLUMBING
L O� BING PERMIT
1 hereby, affirm that I have a certificate of consent to self in- 20-0026 DPW 4/90 i�6f>" R 6e99Y�® 1r PERMIT
76A667A
sure,-or a certificate of Workers'Compensation Insurance,or a
certified ppy.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)
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM ADDRESS f
department. @ FEE LOCALITY •
DcIte Applicant WATER CLOSET(TOILET) .% NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. —
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by
the permit Is for one hundred dollars($100)or loss.) �� LAVATORY ADDRESS IV
I certify that in the performance of the work for which this per-
mi
er- SINK CITY TEL.NO. t ' ?�
mit is issued, I shall not employ any person in any manner so
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR �/�`e
Date. Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �>
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect. HOSE BIB DATE
T— T-
License Number Lic. Clas I
G
FINAL ACCTo L 0
Contractor Date BY33
�, iJe it A
I am exempt under Sec. Q 1 ITEMS
8.8P.C. for this reason Plan check fee ® TOTAL 1 6 o :.ION
Date: PLUMBING PERMIT ISSUING FEE$ (7 CHECK 156.Id-2
Signature TOTAL FEE �r / Q CHANGE ■00
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name CMD-0001 3/ 4/96Low for the following reason (Section 7031.5, Business and
Professions Code): Address 5108 1 Afl11".1v
dI, 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
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 10>
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property fo inspection purposes.
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
XSignature of Permittee Date
COUNTY OF LOS ANGELES I TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1111280020
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: FEES PAID I BUILDING ADDRESS: I
ITR: 4314 LT: 1 UN: .004 I I 6610 OAK AV [
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( TEMP CA 917801309 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
5382-010-051 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 596 GRID: Jl LOCALITY: TEMPLE CITY, Cl
I 147 WATER HEATER(S) 1.00 WTH 16.30 1
TENANT: [ TOTAL FEES 44.10 (ISSUED ON: PROCESSED BY: PLAN BY: I
[ I 111/28/11 SR 1
1OWNER: TEL. NO: IFINAL DATE FINAL BY: CODE: 1
1 , RICKIE _ I 1
166106610 OAK AV I / 1
ITEMP 917801309 1 IDES RIPTION OF WORK 1
I IREPLACE/REPLACE GAS WATER HEATER 1
(APPLICANT: TEL. NO: I
ILUBA, BATIOFF (425) 636-7084- I I
I [SPECIAL CONDITIONS: 1
I
(CONTRACTOR: TEL. NO: I IAPPRbVALS DATE INSPECTOR SIGNATURE
IFAST WATER HEATER (425) 636-7054- 1 1 [
112601 132ND ST. LIC. NO 1 (UNDER SLAB WORK [ [ I
IKIRKLAND WA 98034 036931237 I I I I I
I ] WATER SERVICE
(PLASTIC YIN METAL YIN
(ARCHITECT OR ENGINEER: TEL. NO: 1 I I I I
- I IROUGH PLUMBING
LIC. NO:
I ICAs PIPING
I I I
IGAS VENT I [ I
IHOT WATER HEATER I I I
[ (PLUMBING FIXTURES I I
LAWN SPRINKLERS I I I
]GAS TEST I I I
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I I (UTILITY COMPANY NOTIFIEDI I I
I I I� I I I
IGRAY WATER SYSTEM
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1RfiPORT ID: DPR263 ROUTE TO: BSO508