HomeMy Public PortalAbout5535 ROSEMEAD BLVD_Plumbing__ WORKERS'a I have aSATION DECLARATION a DPW U90 APPLICATION FOR PLUMBING PERMIT
sue.or affirm that I have o s Compensation
at consent ro self in
certified
or a copy
thereof
of Workers , Lob Crahon Ireuronca,oro n
cemy N copy thereof(Sec 3800, Wb C ) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS U
Policy Not 'c�lLZ Company'TRAAS A_�A.16�'
O Certified copy Is hereby furnished
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN(PRINT oa TYPE) ADOMM $S3SRap
department NUMBER FIXTURE OR ITEM a FEE LOCALITY
Date 93-31—
Applicant t j%Mj5 ,In g�1_t a WATER CLOSET(TOILET) 14. 10
NEAaEST
CERTIFICATE OF EXEMPTION FROM WORKERS' BrlTrr+vB� S ' �s ST0
COMPENSATION INSURANCE sLLotkcR OWNER OPRCX T
(This section need net be completed If the work Imrolved by
the permit Is for one hundred dollars({100)or Im) LAVATORY ADpRPcc 7�Lt0 �Ld
I certify that in the performance of the work far which this par-
SINK
ms n issued, I sholl not employ any person In any manner so Cin' Reoch TEL NO
as to become subject to the Workers'Compensation Laws DISHWASHER
tX7slTRAROR
Date—Applicantfer m CiQARLMtIfM
KANTEx.
H! ADORESSCI P6 (0151,1117f* X575
NOTICE TO APPLIf, after making the Certificate of Ex-
emplion,you should become subject to the Workers'Compen• 1
sanan provisions of the Labor Code.You must forthwith comp- CITY s An alp G•Lh TEL NO
Ilywith such provisions or this Perms shall be deemed revok- STATE LIC
WATER NEATER LICENSE NO ( CLASS
LICENSED CONTRACTORS DECLARATION DISTRIQ NO Y
I herebyoff that I am licensed under GAS SYSTEM S OUTS �?O 8 A
prm 3 of t o Chapter V
9(commencing with Section 7000)o/Division 3 of the Btniness T1 ETS OVER ap
and Professions Cade, and my license is in full farce and ef- S PER SYSiFM FINAL
fect 1 S NOSE BIB DATE j —� ATION
License Numbe.470 9 Lic Class a 1208.40 '
6
S N FINAL O
V
Connactor�pLlfaAy.11> �LDats 1�3L" 1z P-4 D l� BY 5_CT.` is
jam exempt under Sec C �� O O RC DIF
3303 1434.30
B 6P C for itis reason PlanZeck f Q'YQ 4
Data PLUMBING PERMIT ISSUING FEE$ IJ 17 fj
SignatureTT
SINGLE FAMILY TOTAL FEE Mo ITEMS
NOME OWNER-BUILDER DECLARATION Plan check applicant TOTA? 2642.
1 hereby affirm that I am exempt from the Controctor's License Name
Law for the following reason (Section 7031 S, Business and
CHECK 2642.70
Professions Coda) Address owe
.001, as owner of the property, will do the work and the City Tel No
structure is not intended or offered for sale(Section 70",
Business and Professions Code)
MD—MI 8/31/95
CONSTRUCTION LENDING AGENCY ►
I hereby offum that there is a construction lending ogency lar 2133 1 PM 4112
the performance of the work for which this permit is issued
(Sec 3077 Ctv 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 101ordinances and State lows regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above mention �d pro airy for mapectlon purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
ature of Permittee Data
COUNTY OF LOS ANGELES TEMPLE CITY p 0508 PLUMING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1212120018
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
LEGAL ID FEES PAID BUILDING ADDRESS
IBR 105 PO 86 PC 9 1 5535 ROSEMEAD BL
IFEE DESCRIPTION QUANTITY DOM AMOUNT I TBMP CA 917801802
ASSESSOR INFORMATION NUMM I I NEAREST CROSS STREET 1
15387-032-058 101 PERMIT ISSUANCE FEE 27 80 I THOMAS PAGE 596 GRID H4 LOCALITY TEMPLE CITY CAI
117 FLOOR DRAINS) 1 00 FIX 16 20 1
TENANT 125 LAVATORIES/SINKS 1 00 FIK 1620 ISSUED ON PROCESSED BY PLAN BY
HOMETOWN BUFFET I TOTAL FEES 60 20 112/12/12 SR
I II FINAL �1 A1��
UP�TS INC TEL )Y CODE
BU
11020 DISCOVERY RD
IEAGAN MN 55121 I 1 MSCRIPTION OF FORK 1
1 I (FLOOR DRAIN AND 1 SINK
(APPLICANT TEL NO I I 1
ISCHNIERE STEVEN (951) 241-6876- 1 I
125251 ALESSANDRO BL I ISPECULL CONDITIONS 1
MORENO VALLEY 92553 I I
I
ISD D�COMNRCORPORATION OF CALIFORNIA TEL
1 (APPROVALS DATE INSPECTOR SIGNATURE 1
117681 MITCHELL NORTH SUITS 100 LIC NO (UNDER SLAB YgRR 1
IRVINE CA 92614 760475
I I IWATER SERVICE r II
I I (PLASTIC YIN METAL Y/N I I
(ARCHITECT OR ENGINEER TEL NO
I I (ROUGH PLUMING 1 I
LIC NO I I
1GAS PIPING
1 GAs VENT I I
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I I HOT WATER HEATER I I I
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1 I PL@49ING FIKTURES II1 .L7 i1� I
1 1 LAWN SPRINKLERS
I I I I
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GAS TEST 1
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(UTILITY COMPANOTIPIED
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I I (GRAY WATER SYSTEM I 1 I
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1 IREPORT ID DPR263 ROUTE TO BS0508
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