HomeMy Public PortalAbout9420 OLIVE ST_Plumbing__ WORKER'S COMPENSATION DECLARATION 76A666 DPW 9/89 APPLICATION
q TION FOR PLUMBING BING P61' MIT
I hel.3by atfirrn that I have a certificate of consent to self insure,
or a cortificate A Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.)
Policy No. Company
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
❑ Certified copy is hereby furnished. BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) gDDRESS �IZL I
Certified copy Is filed with the county building Inspection
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Dale Applicant WATER CLOSETT
•� / NEAREST
,•J C •!.a✓•, ;' �
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE BATH TUB OSS ST.
f
ESSOR
(This section need not be completed If the work Involved by the SHOWER /` MAP BOOK '4 a%L� PAGE Q'7-3, PARCELCJ( 7
permit Is for one hundred dollars($100)or less.) LAVATORY 4--!
OWNERTG
1 certify that in the performance of the work for which this permit r
is issued, I shall not employ any person in any manner so as toMAIL
SINK ADDRESS -��
become subject to the Workers'Compensation Laws.
y� DISWASHER CITY TEL.NO.2 ��'�Ci
Date 1411414_17- Applicant V- ,y fewfl5 CLOTHES WASHER -
NOTIC TO-APPLICANT: If, after making this Certificateof / _ CONTRACTOR � i9As 'L,,L�5•
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS•a7 y,��
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY , safJ3b/✓Lrya1 TEL NO I � "
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER STATE LIC. 1i6J�
(commencing with Section 7000)of Division 3 of the Business and / GAS SYSTEM OUTLETS / LICENSE NO. J38 CLASS B- 1. E.
Professions Code,and my license is in full force and effect. V
DISTRICT NO. PROCESSED BY
OUTLETS OVER � Q
�✓ / 5 PER SYSTEM h
License Number JCC Lic.Class - `�/ t•(J 1
FINAL ,tri VALIDATION
f� /C 7�? DATE `�
Contractor / ')- —`7
Date
❑
FINAL
I am exempt under Sec. _ FOT
I
BAP.C.for this reason
X-6
Date: Plan check fee
PLUMBING PERMIT ISSUING FEE$
Signature
❑ TOTAL FEE d
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name %'�j•,�, ��rn/
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5, Business and Professions Address
Code): /�tt
❑ city {f3 1.L' f}IYt�lL'N t1 Tel.No.
1,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 authorize
representatives of this County to enter upon the above-mentioned
properSy jfor ins tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
• �t C �F7T2ft�i !G Zn �J'�
Signatureof Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0005040038
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
GAL ID: FEES PAID 9420 OLIVE ADDRESS:
ON FILE
FEE DESCRIPTION: QUANTITY: UDM: AMOUNT: TEMP CA 917803156
ASSESSOR INFORMATION NUM E : NEAREST CROSS STREET: ENCINITA
8590-003-017 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY
51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20
TENANT: TOTAL FEES 43.95 SSUED ON: PROCESSED BY: PLAN EXPIRES ON:
05/04/00 UT 10/ 00
OWNER: TEL. NO: FINAL DATE FINAL BY: CODE:
HATLEY FAYE J (626) 287-9307-
9420 OLIVE ST '
TEMP 917803156 DESCRIPTION OF WORK
GAS LINE FOR HVAC SYSTEM
APPLICANT: TE . NO:
CYPRESS HEATING AND AIR COND. -
547 S. LORAINE AVE SPECIAL CONDITIONS:
GLENDORA, CA
CONTRACTOR: TEL. NO: ma. APPROVALS DATE INSPECTOR SIGNATURE
\oe
CYPRESS HEATING AND AIR CONDITIONIN (626) 963-9810- r�'!�<.
547 LORAINE AVE LIC. NO r'r-''� UNDER SLAB WOR
GLENDORA, CA. 91741 593268 C20 *,I.,/
.'.� � �^ y}, I�• ����\ ` WATER SERVICE
ARCHITECT OR ENGI EER: TE 0: �� - -'•�-;�-�_; 1` ` PLASTIC Y/N METAL Y/N
-� INC
I ~` `�` ROUGH PLUMBING
LIC. NO' - —L
7 GAS PIPING
GAS VENT
` ; � " 1%�`� '•� �'f I _���t\ "J OT WATER HEATER
- -- - - ----- - ---- �� PLUMBING FIXTURES
AWN SPRINFLERS
GAS TES
r>_„' �� ,` '�___�� ������`,✓ UT I L I f COMPANY OT I F I ED
CWV
GRAY WATER SYSTE
* ADDITIONAL DATA ON FILE
REPORT ID: DPR263 ROUTE TO: BS0508