HomeMy Public PortalAbout4929 PERSIMMON AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 20.0026 DPW 9189 ^ 'q' FOR
�A PERMIT
CB�p ^yam
76A667A APPL.ICA Y ION 1-®R PLUMBING 1'ERMI fi
I hefeby affirm that I have a certificate of consent to salt insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy tAereof(Sec.3800 Lab.C.)
r COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No. Company
❑ Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDINGn )
Certified copy is filed with the county building inspection ADDRESS d- S%/'�t 416 .
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY _ gam. � 9��(Qv-y�eS
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. "L ag- 7-VSA-
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed If the work involved by the SHOWER MAP BOOK g.s9PAGE095- PARCELO6L7
permit is for one hundred dollars($100)or less.) � LAVATORY OWNER ��v=� �G S _
1 certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to MAIL
become subject to the Workers'Compensation Laws. ® SINK ADDRESS V^/
DISWASHER CITY r- TEL.NO C/� Y7 y,
Date Applicant CLOTHES WASHER r
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code,you must forthwith comply with such
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO. >
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER CL
(commencing with Section 7000)of Division 3 of the Business and LICENSE NO. CLASS
LIC. C
Professions Code,and my license is in full force and effect. GAS SYSTEM �° UTLETS C)
DISTRICT NO. t� PROCESSED BY
OUTLETS OVER ��� ' ��
5 PER SYSTEM
License Number Lic.Class
FINAL VAUbATION
DATE _3C-'
Contractor Date 3I- iirl°LLi1/�
F1 am exempt under Sec. BY 1 j.f
tr"s
BAP.C.for this reason TOTAL 2 0 o 65
Plan check fee
Date: ® r• �.y-i C
Signature PLUMBING PERMIT ISSUING FEE$ � �,) _
TOTAL FEE ® �
❑
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name �i� = ,t!.i 1/
1 hereby affirm that I am exempt from the Contractor's License Law 75 -1 s � �i° eft
for the following reason (Section 7031.5, Business and Professions Address dq/ °j-
Code):
City 2:-H7 c6ee 2Z. Q/f- Tal.N c C>;/g)`fyY-C
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 1 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
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sinnati— ni 10-6140— real
i
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1301230023
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILBGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 4902 IT: 31 BL: F UN: .002 4929 PERSIMMON AV
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:[ TEMP CA 917804105
ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
18574-025-027 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: D4 LOCALITY: TEMPLE CITY CAI
I 147 WATER HEATER(S) 1.00 WTH 16.20 [
TENANT: TOTAL FEES 44.00 ISSUED ON: PROCESSED BY: PLAN BY:
101/23/13 SR
(OWNER: TEL. NO:
IF N T FI AL Y: CODE:
IMCEACHEN BRUCE A;BERNADETTE F (626) 444-8215- I
14929 PERSIMMON AV
TEMP 917804105 IDtSCRIPTIOlt OF WORK
REPLACE WATER HEATER 1
APPLICANT: TEL. NO: I
IXHACHERYAN, MARINE (818) 982-6952- �_ I
113400 SATICOY ST #25 SPECIAL CONDITIONS:
1N HOLLYWOOD CA 91605 [
CONTRACTOR: TEL. NO: [APPROVALS DATE INSPECTOR SIGNATURE
PLUMBING INSTALLERS (818) 982-6952- I
113400 SATICOY STREET #25 LIC. NO [UNDER SLAB WORK 1 1
NORTH HOLLYWOOD CA 91605 915215
I IWATER SERVICE [ [ [
I IPLASTIC Y/N METAL Y/N
4ARCHITECT OR ENGINEER: TEL. NO: I I
I - [ I ROUGH PLUMBING I I I
LIC. NO:
IGAS PIPING I [ I
IGAS VENT I I I
I [HOT WATER HEATER I
I [ PLUMBING FIXTURES
I
I (LAWN SPRINKLERS I [ I
IGAS TEST I I I
[ I I I
I [UTILITY COMPANY NOTIFIEDI [ [
I [CWv 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
[ [REPORT ID: DPR263 ROUTE TO: BS0508 I I I I
I I I I I