HomeMy Public PortalAbout5703 PRIMROSE AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 76A667A
I hereby affirm that.I have a- certificate of consent to self �E 817(2-60) APPLICATION FOR PLUMBING PERMIT
insure,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
PR1 1 �9f� 1. COUNTY OF LOS ELES '—BLULQIl110 AND SAFETY
Policy N�= ranY ernonl-LQd ity j '
'Certified copy it hereby furnished. FOR APPLICANT TO.F,I,L'L IN (PRI TOR T ) BU,I'LD
AODR s 5. 3 Ni Primrose
Certified copy is filed with the county building inspection ;NUMBER FIXTURE OR ITEM • FEE
department. i LOCALITY 3-e-wale Cit
Date. Applicant' WATER CLOSET NEAREST
I� BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCESHOWER OWNER,
J• RY MALL
T
VAO
Earl Rruadl.
(This section need not be completed if the work involved. LAADDRESS 5703 N. Primrose
by the permit. is for. one hundred dollars'($100) or less.) SINK
+ CITY Tem le Cit TEL.NO2S6_6164, U.
I certify that in the performCn the work fnrch this i DISHWASHER Opermit is issued, I shall not any peson i y manner CONTRACTORso as to b 'o subject toers'Comp sa n Laws. CLOTHES WASHER
ADDRESS
135O E. Las Tunas Dr. .
Date Applic
SWIMMING POOL RECEPTOR
NOTI. T. APPLICANT:•'If, after making this Certi ate.of CITY ri el TEL.N — rn
Exemption, you should become subject to the Workers' ( LAWN SPRINKLER SYSTEM STATE LIC. z
Compensation provisions of the Labor Code,you must forth- LICENSE NO. 221751 CLASS C20
with comply with .such provisions or this permit shall be WATER HEATER +
deemed revoked. 1 DISTRICT NO. PR SED I
GAS SYSTEM OUTLETS
INCENSED CONTRACTORS DECLARATION OUTLETS OVER. Q
I hereby affirm that'I ani licensed under provisions.of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division'3 of the.Busi= FINIAL
n.ess and Professions Code,and my license is in full force.and I' DATE VALI DATI. N
effect. ;
FINAL
License ber 22175 Lic.C s C-20 BY
Contr c
I am exempt from the icensing requirements as I am a
Plan check fee
'licensed architect or a registered .professional engineer +
acting 'in my professional capacity (Section 7051, Bus- PLUMBING PERMIT ISSUING FEE$
iness and Professions Code). TOTAL FEE
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason Section 703.1.5, Busi- .-- 1 5 6 2 A .
( City Tel.No. �
ness'and Professions Code): o o,a o 0 5
as owner of the property, am exclusively contracting
.with. licensed contractors to construct the project + 2 0 0 1 0,n 0
,.(Section 7044,Business and Professions Code).
0C
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency I �. 1 5
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordXf
d State laws regulating Plumbing, and hereby
auresentatives of is -County to enter upon the
.abned property inspectio purposes. ;
Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0710170002
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS: I
ITR: 6561 IT: 657 BL: .001 I 1 5703 PRIMROSE AV I
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:1 TEMP CA 917802508
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: BROADWAY
18587-011-002 101 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY, Cl
1 107 BATHTUBS/SHOWERS 1.00 FIX 16.20 I 1
TENANT: TOTAL FEES 43.95 (ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
110/17/07 SR 04/14/08
(OWNER: TEL. NO: 1 IFZNAL DAT F Y: CODE: 1
WENBO, LORI (626) 285-1203- 1 I n 1
15703 PRIMROSE AV 1 I 1.
�+ 3 I
TEMP 917802508 i ID SCRIPTI N OF WORK
IREPLACE SHOWER PAN I
I I
(APPLICANT: TEL. NO: 1 I
ISTONE (626) 282-5117- I I I
1307 N. SAN MARINO SPECIAL CONDITIONS: ]
IS. GABRIEL CA 91775 I I
((CONTRACTOR: TEL. NO: 1 (APPROVALS DATE INSPECTOR SIGNATURE I
SPEEDY STONE PLUMBING, INC. (626) 282-5117- 1 1 1
1307 N SAN MARINO AVE LIC. NO 1 (UNDER SLAB WORK II I
]SAN GABRIEL CA 91775 285376BC26 I 1 1
I IWATER SERVICE
1 1 IPLASTIC YIN METAL YIN I I I
(ARCHITECT OR ENGINEER: TEL. NO: I I I I
1 - I IROUGH PLUMBING 1 1
LIC. NO: _
�I (GAS PIPING ]
I
IGAS VENT 1 I 1
I I IHOT WATER HEATER I 1 I
(PLUMBING FIXTURES I I I
I I LAWN SPRINKLERS
I (GAS TEST I I I
I UT LITY COMPANY NOTIFIED
II I I
iI I Cwv
I (GRAY TER SYSTEM I I I
I awy
] I • _ 1
1 1
1 •I I 1
I I I I
IREPORT ID: DPR263 ROUTE TO: BS0508 I I I I
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