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Home My Public Portal About5749 PRIMROSE AVE_Plumbing__ _WORKER'S COMPENSATION DECLARATION 720-0026 SM67DPw9,69 gPPLICAT10�1I. FOR PLUMBING PERMIT Y. ,. ^J herebigi tgt•I'hava'a certificate of consent.to'self insure., 7uA6f17A or a car cof Worker's Compensation Insurance, or a certified copy tgereof(Sec.3800 Lab.C.) P❑oucy"No. Company COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Certified copy'is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING r_1 Certified Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM ® FEE LOCALITY , Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. COMPENSATION INSURANCE 3 BATH TUB ASSESSOR -y (This section need not be completed if the work Involved by the i SHOWER MAP BOOK ��/ PAGE Q�/ PARCELOJ�O permit is for one hundred dollars($100)or less.) OWNER I certify that in the performance of the work for which this permit LAVATORY CSL Is issued, I shall not employ any person in any manner so as to SINK MAIL become subject to the Workers'Compensatio s. ADDRESS _ 4 �v�' DISWASHER J/ �� CITY �n TEL.NO.ZJJ_Z ZL/ Date ^��^/� Applicant: �-"� CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR acw Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR �� - provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CINTEL.NO.4%, I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER B� IL (commencing with Section 7000 of Division 3 of the Business andSTATE n� LICA'4) C Professions Code,and my license is In full force and effect. 1 GAS SYSTEM OUTLETS �'0 LICENSE NO. —7 C CLkSS & ��■ 1 ��t /� 5OUTLETS PER SYSTEM ,f ,/t DISTRICT NO.. PROCESJED1ByE License Number m 1—'"t"t� Lic.Cl.cl�e1 I/ �ad °fitP_ FINAL �i �� DATE t!r�-��f VA t'TION 28 .4 +a Contractor s Date ' ❑ I am exempt under Sec. FINAL BY CHANGE .0 i Z B.&P.C.for this reason Plan check fee �d b 0. 00011-0001 6/15/93 Date: Signature PLUMBING PERMIT ISSUING FEE$ I3267 1 Alit 8:37 ❑ TOTAL FEE SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address Code): ❑ City Tel.No. I,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 wor for which this permit is issued(Sec.3097, Civ.C.) n 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 representative s County to enter upon the above-mentioned property for specti pur: as, SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKER'SCOIu)PENSATIONDECLARATION 20.0025DPW 9/99 76A087A APPLICATION FOR PLUMBING PERMIT ll I hereby affirm that I have a certificate of consent to self Insure, or a certificate of Worker's Compensation Insurance,or a certified copy thereof(Sec.3800 Lab.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company ❑ Certified copy is hereby furnished. l BUILDING �-f �i FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS I T 10i �C r ❑ Certified copy is filed with the county building Inspection department. NUMBER FIXTURE OR ITEM 0 FEEe.�... f LOCALITY .,��✓��t f« C-1 Dale Applicant WATER CLOSET NEAREST .CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. COMPENSATION INSURANCE BATH TUB � ASSESSOR L' (This section need not be completed if the work Involved by the SHOWER MAP BOOK PAGE PARCEL(:J permit is for one hundred dollars($1 ar less.) LAVATORY OWNE `TA.%,%T I certify that in the performance of a ork for which this permit MAIL is issued, I shall not employ any p rs in any manner so as to SINK ADDRESSj�K become sub'. t to the Workers'Co a ation La 0j DISWASHER CITY TEL.NO Date �P Applicant CLOTHES WASHER CONTRACT NOTICE T APPLICANT: If, afte making this Certificate of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM 40 ��. LICENSED CONTRACTORS DECLARATION CITY TEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000)of Division 3 of the.Business and LICENSE NO. CLCA•SS Q Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS V OUTLETS OVER DISTRICT NO. FIDOCESSED BY / 15P ER SYSTEM _ .T' C License Number Lic.Class F5NALI DATE S �* �'��Y' VA t` ATION :iV= 11 a Contractor Date i 1 I TEMS 0 ❑ I am exempt under Sea BWALrl � 8:s® 2. B.&P.C.to}this reason Plan check fee CHECK Date: , Signature PLUMBING PERMIT ISSUING FEE$ D CHANGE CII:i ❑ TOTAL FEE 19 SINGLE FAMILY L Plan check applicant I 01000-13001 12/ 21 • HOME OWNER-BUILDER DECLARATION Name 218,19 1 PM 12 U I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5, Business and Professions Address Code): ❑ City Tel.No. I,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 v �" Lender's Address I certify that I have read this application and state that the above Informa' orrect. I agree to comply with all County ordinances and S ate Is regulating lumbin and hereby authorize repres ntatives f this Cou to enter the abo e-mentio d propert or Ins ction o e SEE REVERSE FOR EXPLANATORY LANGUAGE 1 Signatu-N bf Permittee D to i1 COUNTY OF LOS ANGELES ' TEMPLE CITY # 0508 eLliM r M1 DEPARTMENT OF PUBLIC WORKS a p 9701 LAS TUNAS PL-Q50800 0 090009 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 n-3--- PHONE: (626) 285-0488 EXT: LEGAL D: FEES PAID B LO TR: 6561 LT: 661 5t2 PRthLRn�-AV- FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802508 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: GARIBALDI 8587-011-010 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY 47 WATER HEATER(S) 1.00 WTH 16.20 TENANT: TOTAL FEES 43.95 ISS ED : PROCESSED BY: PLAN BY: EXPIRES ON: 02/09/00 UT 08/07/00 OWNER: TEL. N0: FINAL DATE 7,�,F,INAL BY: COD LAM TAI H;DONNA - •Z2 Z6Q0 5749 PRIMROSE AV TEMP 917802508 0 WORK JA"71: HEAIFR CHANGt OUT APPLICA . NO: ACTION CONTRACTORS (310) 515-1311- 17111 S. BROADWAY SPECIAL CONDITIONS: GARDENA, CA CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE ACTION CONTRACTORS (310) 515-1311- 17111 S. BROADWAY LIC. NO UNDER SLAB WOR GARDENA, CA 90248 652535C36 WATER SERVICE PLASTIC Y/N METAL Y/N AlICHITECT OR ENGINEER: TEL. 0: ROUGH PLUMBING LIC. N0: GAS PIPING GAS VENT ! HOT WATER HEATER PLUMBING FIXTURES + LAWN SPRINKLERS GAS TEST UTILITY COMPANY NOTIFIED C V GRAY WATER SYSTEM I * ADDITIONAL DATA ON FILE REPORT ID: DPR263 ROUTE TO: BS0508