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WORKERS'COMPENSATION DECLARATION A����1 ����� FOR PL�����I�� PERMIT
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I hereby affirm thof ( have o,certificdte of consent,to self 20-0926 DPW 6187
minsure, or a certificate of Workers'Compensation Insurance, 76AS67A
or a:certified copy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Polt29* C
icy No. I n—Q4Z9mpany-- NA lag- Co
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
❑ Certified copy is filed with the county building Inspec- ADDRESS 10519 Olive St.
tion department. NUMBER FIXTURE OR ITEM (� FEE
LOCALITY Temple City
Date 1-1-90 Appllgant Owen BIOS. WATER CLOSET �� NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUBCROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be complotod If tho work involved by SHOWER " ' 'T Owen Development
the permit Is for one hundred dollars(5100)or loss.) F+ LAVATORY �.; MAIL
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 'rL` CITY Monrovia TEL. N0359-3211
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR Bros, Plumbing.
Date Applicant CLOTHES WASHER '�,''= ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM clrY E1 MOnte TEL. NQ'+43-0078
with comply with such provisions or this permit shall be STATE LIC.
doomed revoked. WATER HEATER LICENSE NO. 231-741 CLASS C36-20
LICENSED CONTRACTORS DECLARATION DJSTRICT NP, PR ESSED BY
GAS SYSTEM OUTLETS
I hereby affirm that I am licensed under provisions of Chapter 9 . 101_s , US(
e
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ALIDATION per,
License Number 231-741Lic. Class C36-20 DATE
Owen Bros. u FINAL
Contractor T��� 9-30-91 BY
BPlC
C
❑ I am exempt under Sec.
LL
B.BP.C. for this reason tl
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ j
Signature
TOTAL FEE
Plan check applicant rr
SINGLE FAMILY
ame
HOME OWNER-BUILDER DECLARATION N
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address KEN �1yo�Jl_
Professions Code): City Tel. No. i IT—El-i j
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section OTOt'l 12.2 o 1-30
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY F.•I.."�''� 1 .r�o•d1
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.).
aODZI-Mr 1 12/13M
Lender's Name
Lender's Address 7490 1 AN10:14
I certify that I have read this application and state that the
Bil-
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
�7
Signature of Permitt e��'� '� Date
• 1 COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1209240022
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
1LEGAL ID: I FEES PAID I BUILDING ADDRESS: I
BK: 224 PG: 98 PC: 1 I 1 10519 OLIVE ST I
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802865 I
ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: I
8586-029-048 101 PERMIT ISSUANCE FEE 27.80 1 THOMAS PAGE: 597 GRID: C3 LOCALITY: TEMPLE CITY, CI
107 BATHTUBS/SHOWERS 3.00 FIX 48.60 I
ITENANT: Ill CLOTHESWASHER(S) 1.00 FIX 16.20 ISSUED ON: PROCESSED BY: PLAN BY:
113 DISHWASHERS) 1.00 FIX 16.20 109/24/12 SR
125 LAVATORIES/SINKS 5.00 FIX 81.00 1 I
(OWNER: TEL. NO: 145 WATER CLOSET/URINAL 3.00 FIX 48.60 IFINAL DATE FINAL BY: CODE: 1
ICHEN, TIM (626) 379-1611- 1 TOTAL FEES 238.40 I
110519 OLIVE ST 1
ITEMP 917802865 1 1IMSCRIPTION OF WORK I
IPLUMBING FOR KITCHEN AND THREE BATHROOMS REMODEL 1
I 1 I I
(APPLICANT: TEL. NO: I I
ITSH CONSTRUCTION & DEVELOPMENT (626) 688-6255- I I
15605 TEMPLE CITY BL. I ISPECIAL CONDITIONS: I
1TEMPLE CITY CA 91780 I I I
ICONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE 1
ITSH CONSTRUCTION AND DEVELOPMENT (626) 688-6255- 1 1 I
15605 TEMPLE CITY BLVD. #B LIC. NO I (UNDER SLAB WORK I I I
ITEMPLE CITY, CA 91780 952913-B I I I I I
I I IWATER SERVICE I I I
I I IPLASTIC YIN METAL YIN I I I
ARCHITECT OR ENGINEER: TEL. NO: I I I I I
I -LIC. No: I IROUGH PLUMBING I I
1
(GAS PIPING
GAS VENT
I I I I I I
HOT WATER HEATER
I I I 1 I
I I IPLUMBING FIXTURES I I 1
I 1 I I I I
ILAWN SPRINKLERS I I I
I I I I I I
I I IGAS TEST I I
(UTILITY COMPANY NOTIFIEDI I 1
I ICWV I I
(GRAY WATER SYSTEM 1 1 I
I 1 1I I I
I I I I r uI
I I I I I I
I i l
1 IREPORT ID: DPR263 ROUTS TO: BS0508 I I I
I I I I I I