HomeMy Public PortalAbout6018 RENO AVE_Plumbing__ 1 r
L'_11.)RKERS'COMPENSAMN DECLARATION 20-0026 DPW 4387 APPLICATION FOR PLUMBING PERMIT
4=h&e6y,y affirm that I have a certificate of consent to self in- 76A667A
surer cr a certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86)
certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company
• COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS600
d yd
department.�T�/ Cys.,,- NUMBER FIXTURE OR ITEM @ FEE LOCALITY ! q`
Date 2- —Z—O 0 Applicant 9 ,c� �r LIlL�G4s j WATER CLOSET(TOILET) NEAREST l C/
CERTIFICATE OF EXEMPTION FROM WORKERS' I BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER �' D
(This section need not be completed if the work involved by MAIL
the permit Is for one hundred dollars($100)or less.) , LAVATORY ADDRESS
1 certify that in the performance of the work for which this per- , SINK p
mit is issued, I shall not employ any person in any manner so CITY IL TEL. NO. ,?_00 '9
as to become subject to the Workers' mpensation Laws. DISHWASHER ` v I
`[J fY _ CONTRACTOR
Date o U Applicants f CLOTHES WASHER a
NOTICE TO APPLICANT: If, after ming this Certificate of Ex- ADDRESS
a 6deNtE 1005
emption,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR
CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR E D F
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINA VAL &TION >'
fect. DATE 1L
License Number Lic. Class O
V
FIN Q
Contractor Date BY O
F-
I am exempt under Sec. 2 9 01, 9 A V
W
CL
B.&P.C. for this reason Plan check fee � 0 0 0 0 0 5
, rn
Date: �
PLUMBING PERMIT ISSUING FEE$ Q
Signature I a - 4(150
TOTAL FEE
SINGLE FAMILY Plan check applicant
o 0 0 4.0.5 0 65
HOME OWNER-BUILDER DECLARATION PP
I hereby affirm that I am exempt from the Contractor's License Name 0 2 L 38 8
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 'WQt�/c- �
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
a ve-mention d property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
O _
ignature of Permittee Date
O ,
COUNTY OF LOS.ANGELES TEMPLE CITY # 0508 "MG-PERMI T
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS 'PL-050879910140006
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL I : FEES PAID B LD NG R SS:
TR: 5904 LT: 144 PMI 0_1,
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801530
ASSESSOR I OR AT 0 BER: NEAREST CROSS STREET:
5384-017-008 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY
07 BATHTUBS/SHOWERS 1.00 FIX 16.20
TENANT: 11 CLOTHESWASHER(S) 1.00 FIX 16.20 ISSUED ON: PROCESSED LA B --EXPIRES ON:
25 LAVATORIES/SINKS 1.00 FIX 16.20 10/14/99 UT 04/11/00
45 WATER CLOSET/URINAL 1.00 FIX 16.20
OWNER: TEL. NO: 51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20 FINAL DATE FINAL BY: CODE:
MERCADO6018 BENAVTO ;DELIA (626) 962-6341- TOTAL FEES 108.75 �`2,1
TEMP 917801530 DESCRIPTION Of WORK
PLUMBING FOR NEW BATH ADDITION
APPLICANT: TE0:
SAME AS OWNER -
SPECIAL CONDITIONS:
GELES Co
CONTRACTOR: TEL. NO: ®cJ APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER -
LIC. NO SLAB 0
i
WATER SERVICE
A PLASTIC Y/N METAL Y/N
ARCHITECT OR G EER: T 0:
LIC. N 1111111 OUGH PLUMBING
S PIPING /
W
GAS VENT
V��
L7
LI )U LC 0 ILF01AKS 0 ER
PLUMBING FIXTURES
C o x a,�1� SP NK E S
❑ r�V I t'� GAS TEST
❑
�y TIL COMPANYOT F D
.fl46'i ❑ O�
se►vice Th6t� CWv
GRAY WATERSSE
REPORT ID: DPR263 ROUTE TO: BS0508