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Home My Public Portal About5520 PERSIMMON AVE_Plumbing__ AN ' / ` i/ ?e ! WORKERS'COMPENSATION DECLARATION 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT I hereby,jafArm t)k�t I have a certificate of consent to self in- 76A667A sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86) certified copy thereof (Sec. 3800, Lab. C.) Policy No. I O17<30. Company SArd-e_ .u� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS R' Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) Certified copy is filed with the county building inspectionADDRESS I M(V-\ department. NUMBER FIXTURE OR ITEM @ FEE �. LOCALITY Date ►a(� ( 19 9 Applicant 119 E WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. t (�! COMPENSATION INSURANCE SHOWER OWNER FAO fte (This section need not be completed if the work involved by MAIL the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK CITY TEL. NO. mit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR r `- ,, Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR D C, 1C emption,you should become subject to the Workers'Compen- CITY TEL. NO. sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM tl`c ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTR NO. PROSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �GJ� `(/11 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDION '' ��'I �/__ DATE CL License Number N 3 Lic. Class ?3 V /� Q Pian Date 0 cw � BI Contractor (ziryisfyAt / O ❑ I am exempt under Sec. W B.BP.C. for this reason Plan check fee 2 0 9 6 3 A Poo. # 0 0 0 0 0 5 fA � � Date: PLUMBING PERMIT ISSUING FEE$ - - 4650 0 Signature TOTAL FEE SINGLE FAMILY 0 0 0 [j.6 5 0= k hec HOME OWNER-BUILDER DECLARATION Plan capplicant I hereby affirm that I am exempt from the Contractor's License Name 1 0.21 `88 Law for the following reason (Section 7031.5, Business and Professions Code): Address ❑ I, as owner of the property, will do the work and the City Tel. No. 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 ob e- entioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P rmittee J Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers'Compensation Insurance, 76A667A or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified.copy is filed with the county building inspec- ADDRESS (f93 tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Appligant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST. %A e C COMPENSATION INSURANCE OWNER [ (This section need not be completed If the work Involved by MAIL SHOWER TMJ the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESSd 1 certify that in the performance of the work for which this _ / permit is Issued,I shall not employ any person in any manner SINK CITY / TEL.NO. �-g�Al so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. 'REMD BY I hereby offirm•that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS i � (commencing with Section 7000)of Division 3 of the Business i OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VA (DATION License Number Lic. Class DATE Al -A's A I FINAL Contractor Date BY ❑ 1 am exempt under Sec. U B.BP.C. for this reason / y IL Plan check fee 2 Z ® Z Date: P4 PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE SINGLE FAMILY Plan check applicant MI - HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address w- Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. 1, as owner of the property, will do the work and the ` _ - ((( structure is not intended or offered for sale (Section 707"L �_ L1— -,_-.. 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 ;�;!'.i'_,;)L(i �I'.+'i_:::•��: Lender's Address �'L_ r ri ;: 7 1 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 property for inspection Our oses. SEE REVERSE FOR EXPLANATORY LANGUAGE iz�'� 2 Signature of Permittee ffate I COUNTY OF LOS ANGELESi TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS I BUILDING AND SAFETY / LAND DEVELOPMENT 9701 LAS TUNAS PL 0508 0308220014TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID' FEES PAID BUILDING ADDRESS: TR: 13613 LT: 133 5520 PERSIMMON AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802805 ASSES 0 IO B R: NEAREST CROSS STREET: LIVE OAK 8573-009-013 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: C3 LOCALITY: TEMPLE CITY 47 WATER HEATERS) 1.00 WTH 16.20 TENANT: TOTAL FEES 43.95 ISSUED ON: PROCESSED : P B EXPIRES ON: 08%22/03 JK 02/18/04 OWNER: TEL. NO: F IA DAT FINAL CODE: BLANCO LINDA (626) 452-0242- n ' 5520 PERSIMMON AV 2 TEMP 917802805 DE CRWTION0 0 C/PWATER HEATER APPLICANT: TEL. VAL HALAJIAN 01 (818) 407-1247- ; 7338 ETHEL AVENUE SPECIAL CONDITIONS: N HOLLYWOOD 91605 I CONTRACTOR: TE O: AIPROVALS DATE INSPECTOR SIGNATURE ALAP ASSOCIATES (818) 407-1247- 7338 ETHEL AVE LIC. NO UNDER SLAB WORK NORTH HOLLYWOOD 771905C36 JJ WATER SERVICE PLASTIC Y/N METAL Y/N ARCHITECT OR ENGINEER. T L. 0: - RUG PLM G LIC. NO:; `GAS PIPING GAS VENT H PT WATER ER a 2 PLUMBING FIXTURES LAWN SPRINKLERS GAS TEST UTrL-17Y COMPANY 0 I I u GRAY WATER SYSTEM i I I REPORT ID: DPR263 ROUTE TO: BS0508 I I