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Home My Public Portal About9634 OLIVE ST_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT � J "e{S1Tgffifm thbt I have a certificate of consent to self 76A667A ure,br a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ID Certified copy is filed with the county building inspec- ADDRESS ( J 6� 04. tion department. NUMBER FIXTURE OR ITEM FEE LOCALITY Es �f WATER CLOSET A 100 Date AppliSant CROSS NEARESTT . CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB COMPENSATION INSURANCE SHOWER0yV OWNER (This section need not be completed If the work involved by MAIL the permit is for one hundred dollars($100)or less.) LAVATORY 0 ADDRESS 1 certify that in the performance of the work for which this // permit is issued, I shall not employ any on in an manner SINK CITY TEL.N0. so as to become subject to the r Compens L DISHWASHER CONTRACTOR DateAppl I CLOTHES WASHER ADDRESS NOTICE TO APPLI ANT: after making t s C rtificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. RO ESSED I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7006)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is In full force and effect. 5 PER SYSTEM FINAL VALID TION IV p / u License Number DATE Lic. Class 104XI 10-P /2 FIN& C' Contractor Date BY lk 7 ❑ I am exempt under Sec. F C B.BP.C. for this reason IL Plan check fee ® v Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE I A10S SINGLE FAMILY a Plan check plicant HOME OWNER-BUILDER DECLARATION Name ,5000�01,,,toc-P— G��.e.`- .0-51 2 9 A I hereby affirm that I am exempt from the Contractor's License Address / #•o o 0 0 0 5 Law for the following reason (Section 7031.5, Business and 7 l Professions Code): City CIO Tel. No,.^��a �� 1 o - 4(150 !h' 1, as owner of the property, will do the work and the o 0 0 4 Q 5 05x IIII structure is not intended or offered for sale (Section ® 7044, Business and Professions Code). O 7.2 5 8 6 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 Pool ordinances and State laws regulating Plumbing, and hereby authorizerepr �entatives of this County to enter upon the above- ned pro r inspection purposes. ��. SEE REVERSE FOR EXPLANATORY LANGUAGE Lure of Pe a Date ORKER§'COMPENSATION DECLARATION- -y, ff};�It,tho I have a certificate of consent to self in- •76A667A S Lir a certificate o?Workers'Compensation Insurance,or a CE 817(REV.8/86) certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No..,.— Company a Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING / `J� Q�Jv�.-;• s' Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE It LOCALITY Date Applicant WATER CLOSET(TOILET) 6 NEAREST r� / CERTIFICATE OF EXEMPTION FROM WORKERS' / BATH TUB to CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars($100)or less.) LAVATORY I, ADDRESS I certify that in the performance of the work for which this per- SINK CITY TEL. NO ! �/ mit is issued, I shall not employ any person' any manner so C. as to become subject to f e Worke C 1 Laws. DISHWASHER CONTRACTOR1. Dat A c CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: I ter mating this Certificate of Ex- /f emption,you should become subject to the Workers'Compen- lb � CITY 6400 sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION ` DISTRICT-LIQ. r� P CESSED B I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM 'a OUTLETS G od 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 1 5 PER SYSTEM FINALV (DATION fect. DATE C License Number Lic. Class err z �/' FINAL �� Contractor DateA 910 r e / BY A 1 am exempt under Sec. glnw /! l/ IE LU lOv 9, B.BP.C. for this reason ► g Plan check fee Date:. PLUMBING PERMIT ISSUING FEE$ (� S Signature i TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant c 9 4 1. 1 A I hereby affirm that I am exempt from the Contractor's License Name **e,-_ v�Lo ®(i�r✓j,Y) Law for the following reason (Section 7031.5, Business and #-000005 Professions Code): Address �� ,(/�� f"� Ott "o o 64.5 0 I; as owner of the property, will do the work and the [ C Tel. N 7Z structure is not intended or offered for sale(Section 7044, Business and Professions Code). I , o664,5 0 o CONSTRUCTION LENDING AGENCY i Oki 8-88 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 i above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize repro tatives o County to enter upon the above-me ed propeof f r ction purposes. 2SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of Permittee Date COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1103020017 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: ILEGAL ID: I FEES PAID I BUILDING ADDRESS: I ON FILE I [ 9634 OLIVE ST I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:[ TEMP CA 917803249 (ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: TEMPLE CITY 8589-002-015 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 597 GRID: A4 LOCALITY: TEMPLE CITY, Cl 107 BATHTUBS/SHOWERS 1.00 FIX 16.30 [ (TENANT: 125 LAVATORIES/SINKS 2.00 FIX 32.50 (ISSUED ON: PROCESSED BY: PLAN BY: 145 WATER CLOSET/URINAL 1.00 FIX 16.30 103/02/11 SR I 147 WATER HEATER(S) 1.00 WTH 16.30 1 (OWNER: TEL. NO: 151 LOW PRS GAS 5 OUTLET 1.00 SYS 16.30 IFINAL DATE FINAL BY: CODE: 1 IHOCCOM LAWRENCE D CO TR HOCCOM TRUS - I TOTAL FEES 125.50 1�i 19634 OLIVE ST 1 1/ I ITEMP 917803249 1 lbgSCRIPTIOS OF WORK 1 [ I ITO FINALIZED EXPIRED PERMIT FOR ADDITION PLUMBING, GAS LINE 1 I I ISPA HEATER, FIRE PIT AND RELOCATE WATER HEATER I [APPLICANT: TEL. NO: I I I IPFEIFFER, BRUCE (626) 278-2187- I I 1409 MEADOW IN. 1 ISPECIAL CONDITIONS: 1 (MONROVIA I I I I [CONTRACTOR: TEL. NO: 1 (APPROVALS DATE INSPECTOR SIGNATURE [ [PFEIFFER, BRUCE (626) 446-5999- 1 1 I 1409 MEADOW LANE LIC. NO I (UNDER SLAB WORK [ I IMONROVIA, CA 91016 NONE I I_ [ [ [ I I IWATER SERVICE I I I I IPLASTIC YIN METAL YIN I I I ARCHITECT OR ENGINEER: TEL. NO: I I I I I I - [ IROUGH PLUMBING LIC. NO: I [ I [ IGAS PIPING I I I I I I I i I GAS VENT I I I [ I IHOT WATER HEATER I I I [ I IPLUMBING FIXTURES I I [ I I I I I ILAWN SPRINKLERS I I I I I I I I [GAS TEST I I I (UTILITY COMPANY NOTIFIEDII I I I ICWV 1-1 I I I I IGRAY WATER SYSTEM [ I I I I I I I I I I I I [ I I I [ I I I I I I I I I I I I I IREPORT ID: DPR263 ROUTE TO: BS0508 I [ I I I I I I I I