HomeMy Public PortalAbout5546 ROSEMEAD BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION
I hereby, affirm that I have a cer ldittd of consent to self in- DPW 4 APPLICATION FOR PLUMBING PERMIT
sure,or a certificate of Workers'Compensation Insurance,or a 76A667A ^
certified copy thereof(Sac 3800, Lob C )
Policy No Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished
Certified c is filed with the county builds spe FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �• // �J .w�. d�vv
copy ty tg in coon ® ADDRESS SJ�(O / RGTV rJ
deportment NUMBER FIXTURE OR ITEM
LOCALITY Twp u, Cf�
Date-Applicant WATER CLOSET TOILET)
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS STSs IA-S rIl&,Ot
COMPENSATION INSURANCE SHOWER OWNER J AI r TSS G
( (This section need not be completed If the work Imrolved by �� ��y
the Permit is for ono hundred dollan($100)or less) LAVATORY MAIL
ADDRESS �`, Lei-7s.ac 1 ts(Vd
I certify that in the performance of the work far which this per- �ve�ire C.A�
mot is issued, I she I not employ any person in any manner to SINK �y TEL rp
as tobecom sub r to the Workers Compensation Laws
DISHWASHER CONTRACTOR � �rfA^XcvP�B ca
Date Apphcont CLOTHES WASHER ADDRESS 22/ /(/ ` /�}� ��
NOTICE TO APPLICANT If otter king this Certificate of Ex- SWIMMING POOL RECEPTOR CITY r M
emption you should become subject to the Workers'Compen- I '7 TEL NfB�
nation provisions of the Labor Core you must forthwith comp LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok-
ed WATER HEATER LIICENJSE NOp/ -a-SS C--=56
LICENSED CONTRACTORS DECLARATION DISTRICT t�.0,0 J PROCESSED BY
I hereby affirm that I am licensed under provision of Chapter GAS SYSTEM OlfT1E15
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is In full force and of- 3 PER SYSTEM FINAL VALIDATION
fect Z
License Number 51/42- / LIc Class HOSE BIB 01 DATE „I LL
Lk%Aw_P[BCX q'�' IeL7IcE D BY KCT,` 0
contractor Dote BY T
I am exempt under Sec 3303 75.61J p
B 8P C for this reason 1 ITEMSPlan check fee m
-Date PLUMBING PERMIT ISSUING FEES o! p ► TTtO11TC�ALVy 75 _ tS(�
Signature _ ]dBeMFE 75:68 68
SINGLE FAMILY TOTAL FEE /p Q 4fn7hMlfnYlV7GG Ute
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor s License Nome
Law for the following reason (Section 7031 5, Business and - 0000-W01 7/10/95
Professions Code) Address
I, as owner of the property, will do the work and the CSN Tel No 1229 1 AN 8:41
structure is not intended or offered for sale(Section 7044,
Business and Professions Code) Poo.
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 to Name
Lender s Address
I certify that I hove 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
above-mentioned props_ rty for inagperion Purpos
�l,(�f�?/Jsrf.Q �D SEE REVERSE FOR EXPLANATORY LANGUAGE
Si arure of Permittee Date
• COUNTY OF LOS ANGELES TEMPLE CITY # 0508 I1T
DEPARTMENT OF PUBLIC WORKS 9701 LAS TURAS 990 8
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT
LEGAL ID FEES PAID BUILDIN
ON FILE
FEE DESCRIPTION QUANTITY UOI AMOUNT: 17801801
ASSESSOR INFORPLATION NUMBER NEAREST CROSS STREET BROADWAY
5387-1027-024 ON PLANCHECK FEE 599 70 583 20 THOUS PAGE 596 GRID- H4 LOCALITY TEMPLE CITY
01 PERMIT ISSUANCE FEE 27.75
OS BACKFLOW DEVICE(S) 1 00 DEV 16 20T9M ON PROCESSED BY: -
21 HOSE BIBB(S) 1 00 FIX 16 20 10/22/99 UT - 04/7 100
25 LAVATORIES/SINKS 13 00 FIX 210 60
OWNER TEL NO: 27 PRESS REG DEVICE(S) 1 00 DEV 16 20FINAL DATE -
TSA'6'
L,SYOU H,CHIM ZONG;CHIN CH (626) 575-1200- 29 ROOF DRAINS) 48 00 FIX 777.60
10050 GARVEY AVE 45 WATER CLOSET/URINAL 13 00 FIX 210 60 -F WORK
EL MONTE, CA 91733 47 WATER HEATERS) 13 00 WTH 210 60 DESCRIPTION
TOTAL FEES 2,068 95 PLUMBING FOR CWERCIAL BUILDJMG FOR RETAIL, OFFICE AND
MEDICAL OFFICE L SP MK�,
APPLICANT TEL. NO
M T S CONSTRUCTION (626) 350-1098-
2728 TYLER AVE SPECIAL CONDITIONS:
EL MONTE, G
CONTRACTOR TEL NO - �pS PNGELES co APPROVALS DATE INSIPCTOR SIGNATURE
M T S CONSTRUCTION (626) 350-1098-
2728 TYLER AVENUE LIC. MO UNDER SLWtr
EL MONTE, G 91733 468673036 WATER 5ERV";E
/ PLASTIC YIN METAL Y/N
ARCHITECT DR ENGINEER TEL NU.
ROUGH PLUMBING
LIC 0
0 111 llll
GAS VENT
PUBLIC WORKS HOT WAM-M�
PLUMBING FIXTURES
> NI
LAWN SPRINKLERS
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ervice Tha��ct�
REPORT ID DPR263 ROUTE TO BS0508