HomeMy Public PortalAbout9624 OLIVE ST_Plumbing__ WORKERS'COMPENSATION DECLARATION I APPLICATION FOR PL;UMBI.NG PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure, or a certificate of Workers'Compensation Insurance; CE 817(REV.10/81)
" ora . _. co .y.thereof(Sec. 3800, Lab. C.) �. COUNTY OF LOS ANGELES. /� ' BUILDING AND SAFETY
Policy Not 43 Company
❑ Certified copy is hereby#urnished. BUILDING
1 9�.2l� �.�/
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN(PRINT'OR TYPE) ADDRESS 1,101901 ,
• NUMBER FIXTURE OR ITEM @ FEE
tion epartm nt. I LOCALITY
S� WATER CLOSET
Date � Appli4ant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. +.
COMPENSATION.INSURANCE i SHOWEROWNER soh
� ' ' - �v.
(This section need.not,be completed if.the work involved by MAIL
the Permit Is for one hundred dollars($100)or less.) LAVATORY , ADDRESS
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner i SINK CITY �"G TEL. ��--�7�
so as to becoine subject.to the Workers' mpensa ion Laws. I '
DISHWASHER
e CONTRACTOR��j ,
Date -Applicant �� ( CLOrHES:WASHER
PP ADDRESS
NOTICE TO APPLICANT; if:; after making this Certificate 'of
Exemption, you should become subject. to the Workers' SWIMMING POOL RECEPTOR'
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY a� , • TEL.N
with comply'with such provisions or this permit shall be STATE: LIC.
deemed revoked. WATER HEATER LICENSE NO.�r/� ` CLASS
LICENSED CONTRACTORS DECLARATION I DISTRICT NO. P CESSED BY
I hereby affirm that I am licensed underprovisions of Chapter 9 I GAS SYSTEM' OUTLETS.
0.
(commencing with.Section 7000)of Division 3of the Business OUTLETS-OVER
and Professions Code;and'my license is in full force and e 41 O
effect. 5 PER SYSTEM. FINAL' 0
DATE VALIDATION
' License NumbeF2 Lic. Class � . 99
/ FINAL O
Contractorz/01, 11 ' X Date a 'BY
❑ I am exempt under Sec.
B.&P.C: for this reason- z
Plan check fee-
Date:
ee Dater PLUMBING PERMIT ISSUING FEE$ Sd ,
Signature
j
TOTAL FEE d
Plan check applicant �' 6
SINGLE.FAMILY
HOME'OWNER-BUILDER DECLARATION Name LP 6 . ,ee64Ae/
I.hereby affirm that I orrl;exempt frorti the Contractor's License Address. /?/" z 2 2.a I 'A
Law for the following reason (Section 7031.'5, Business and 7 � f'.'../d 6. �.
Professions Code): - o'o 0 0`o
City ��sq/ �`` - Tel. No.��77�C'Q r 5
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section. j'o o 3 1k'5 0
7044, Business.and Professions Code.). . I ► '0 . 0311505
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction len..ding agency for 0 5,.2 5—8 3
the.performance of the work for which ttris-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 enterupon the
above-. ration
ed property for inspection purp ses.
I
' � SEE REVERSE FOR EXPLANATORY LANGUAGE •
Signature of Permittee Dotd'
7MS7-CM17-11-57 -
APPLICATION FOR PL4UMB.ING PERMIT 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A.LAMSIE, Count eer ADDRESS L
CASSATT D. GRIFFIN,Supt of wilding LOCALITY �/1���� �i 1 T
FOR APPLICANT TO Fat. IN CROSS sr.
NUMBER FIXTURE OR ITEM OWNER
WATER CLOSET �
IL
BATE TUB ADDRESS
SHOWER CITY' [?J TEL01 NO. 1C QD
LAVATORY CONTEACTOR ^ S' /� "Bi
snm ADDRESS. 11 1)LLt pJ_v p
DISHWASHER CITY be/'X: TEL NO. 6Z e�74
LAUNDRY TUB
CONTRACTOR'S 3COUNTYTAE 13REGISTRATION NO.
CLOTHES WASHER DISTRICT.NO: GROUP ONE I R FOR INSPECTION.
WATER HEATER t
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL
I, INSPECTION RECORD _
1 S C7
i
t"r92 IS fill n.0 c= it-/+-P
APPROVALS
$1.00.PER ITEM DATE INSPECTOR'S SIGNATURE
OR F>STURE $•I ��®
UNDER SLAB WORK
PERMIT $ 00 ROUGH PLUMBING
TOTAL FEE 0V cAs Plmma
I. HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY HOT WATER HEATER b9......-,4
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. PLUMBING FIXTURES
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR GAS TEST f :✓ 1', Z+
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ,
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ; UTILITY CO.NOTIFIED
DESCRIBED RESIDENTJA!�,PROPERTY.
SIGNATURE
OFPERMI - FINAL
i ROBERT A.WOOD.
OF VALIDATIONOSUPERVISING MECHANICAL ENG'R
CII. - N.o. �
k
-s 21 5 A. 9Q 0iD
w _ . 00
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 t PLUMBING•PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS PL 0508 9707290032
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CI.TY CA
PHONE: (818) 285-0488 EXT:
LEGAL D: FEES PAID-- GADDRESS:
ON FILE 9624 OLIVE^ST
FEE DESCRIPTION: QUANTITY: UON: AMOUNT: TEMP CA 917803249
ASSESSOR INFORMATION l NEAREST CROSS STREET: TEMPLE CITY BLVD.
8589-001-016 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A4 LOCALITY: TEMPLE CITY
47 WATER HEATER(S) 1.00 WTH 16.35
TENANT: 1 TOTAL FEES 44.10 ISS D 0 : RO ESSED : P EXPIRES ON:
07/29/97 TC 07/29/98
OWNER: TEL. O: FINAL -DATE FINAL Bn COD
BURNHARDT GRETA D
9624 OLIVE ST I
TEMP 917803249 DTTCRIPTION OF WO -
CHANGE OUT OF WATER HEATER SAME OCATION'
APPLICANT:
RBI INC. (626) 286-7279-
SPECIA CONDITIONS:
rl 5 F-,
CONTRACTOR: TEL. 0: I a. ' �� -�` � ,� APPROVALS DATE INSPECTOR SIGNATURE
RBI INC. (909) 594-3686-
3946 VALLEY BLVD. UNIT D LIC. NO I a°`�` "�, �; �''• UNDER'SLAB WORK
WALNUT, CA. 91789 683107 C36 ��' /•' `a, �,.�'' 'a
WATER{SERVICE
PLAST.0 Y/N METAL Y/N
ARCHITECT ENGINEER: 0: - t ;, b',' �f `t;•_r3ri- �. ,;� '/
0 G LUM NG tee/
LIC. N0: x i -.I i;
1- - ; - GAS PIPING
GASVENT
j. I' ,I '- '1.i i J ."�• yOAA HEATER
I
PLUMB INU FIXTURES
I `J 2;`,, f :_'; - ''' / �;,�+ ✓terLAWN ,SPI LRS
GAS TEST
UT M TY COMPANY NOTIFIED
CWV
1� I
I
IZEPORT ID: DPR263 ROUTE TO: BS0508
i