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WORKERS'COMPENSATION DECLARATION ?I: APPLICATION FOR PLPMBINC PERMIT
I hereby affik}n that I haven certificate of consent to self 76A667A
insuY,e, or a Atificate ot WorkerO'Compensation Insurance, CE 817(REV. 10/81).
or a certified copy thereof(Sec: 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N.a. 1° Company
C1 Certified copy is hereby furnished. BUILDING
Certified copy is filed with the county buildfng,inspec-
FOR APPLICANT TO FILL.IN(PRINT OR TYPE) ADQRESS
tion department. NUMBER FIXTURE OR ITEM @ FEELOCI LITY T�.�p,.
�� Ce
Date: Appli4ant WATER CLOSET NEAREST! / /
BATH TUB CROSS ST. { O 1-M 4,�C� ^A%. . "
CERTIFICATE OF EXEMPTION FROM WORKERS' .�.r
COMPENSATION INSURANCE OW ER
(This section need not be completed If,the work involved by SHOWER tr. S
the permit is for one hundred dollars $.100 or less. MAIL
P ( ) ) LAVATORY l ADDRESS
I certify that in the performance of the.work for which this
permit is issued,I shall not employ any person,in any manner SINK CITY TEL.NO:
• so as to•become subject to the W rkers' o p .saWOW .IDISHWASHER. !
Date��—�� IAG - CONTRA6TOR
4pplican, CLOTHES WASHER' ADDRESS Ave;NOTICE TO APPLICANT: If., .aft making t Certificate of ? ( 0 r. In, A
SWIMMING POOL RECEPTOR
Exemption, you should become'subject t the!-Workers' CITY /� y„1 TEL. NO.
Compensation:provisions of the Labor Code, you must forth= .&-4, v
with comply with. such provisions or this, permit shall be LAWN SPRINKLER SYSTEM STATE'. -. LIC.
deemed revoked. WATER HEATER Ka.v �`
O /1�E 1'1f NO. CLASS.
G
LICENSE.
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P OCESSED BY
I.hereby off irm.that I am licensed'under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions`Code,and my license is in full force and effect.. 5 PER SYSTEM FINAL VALIDATION }
3 7. 06 / c�.... ?�//' DATE,
License Alumber. Lic. ClassJ� C
r FIN t7
' Contractor P L7�"^' I Date
—�:� e IM
`0, I am exempt uncle g$ec. O
B.BP.C. for this reasond
Pari check fee
PLUMBING.PERMIT ISSUING FEE$ d ® r�-
Signatur TOTAL FEE d
'Plan check applicant `
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION 'Name
hereby affirm-that I am.exempt from the Contractor's License Address
Law for the.following reason (Section. 1031.5, Business and
Professions Code): City Tel. No.
0 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). , 4.53 6.6 A
i
CONSTRUCTION'LENDING AGENCY # 0 0 0 0 0 5
I hereby affirm that there is a.construction lending agency for
the performance of the work for which this permit-is issued a;° 4 Q.5 0
(Sec. 3097; Civ:`.C.).
° 4Q5'0�
Lender's Name -
0 (194-- 86
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 A
authorize representatives of this County to enter upon the
lbove- do d p p ty f ' sP ction purposes.
/ SEE REVERSE FOR EXPLANATORY LANGUAGE ;
r �1p
Signature ermittee Date.
4
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1403120008
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS: I
ITR: 5904 IT: 66 UN: .002 I 1 6206 RENO AV 1
I FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:1 TEMP CA 917801534 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: LONGDEN 1
5384-004-001 01 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 596 GRID: H2 LOCALITY: TEMPLE CITY CAI
I 107 BATHTUBS/SHOWERS 1.00 FIX 16.20 I
(TENANT: 125 LAVATORIES/SINKS 1.00 FIX 16.20 (ISSUED ON: PROCESSED BY: PLAN BY:
TOTAL FEES 60.20 103/12/14 SR 1
10WNER: TEL. NO: 1 1FINAL IIATE FINAL BY: CODE: I
ICANOY, EDDIE/LOURFIMA (626) 285-0438- 1 I
16206 RENO AVENUE 1 1 ' 7 1 q
TEMPLE CITY CA 91780 1 1D S RIPTION F WORK 1
REPLACE BATHTUB/SHOWER AND WATER CLOSET 1
(APPLICANT: TEL. NO: I I
1SAME AS OWNER - 1SPECIAL CONDITIONS: 1
I
I
1 1 1 1
(CONTRACTOR: TEL. N0: I 1APPROVALS DATE INSPECTOR SIGNATURE
1SAME AS OWNER LIC. NO I (UNDER SLAB WORK 1 I I
I I IWATER SERVICE 1 I
IPLASTIC Y/N METAL Y/N I I
(ARCHITECT OR ENGINEER: TEL. NO: I I
1ROUGH PLUMBING I I
LIC. NO: I (GAS PIPING I I 1
IGAS VENT I I I
IHOT WATER HEATER 1 I I
IPLUM.BING FIXTURES I I I
I I ILAWN SPRINKLERS I I I
I I IGAS TEST 1 I I
1 1UTILITY COMPANY NOTIFIEDI I 1
I I ICWV I I I
I I 1GRAY WATER SYSTEM I I I
I I I I
I I I I I
I 1 I I 1
IREPORT ID: DPR263 ROUTE TO: BS0508 1 1 I
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