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HomeMy Public PortalAbout5701 ROSEMEAD BLVD_Plumbing__ • WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUM ING PERMIT •y`affirm that I have a certificate of consent to self 20-0026 DPW 6/87 I qr a certificate of Workers''Compensation Insurance, 7GA667A rtified copy thereof(Sec. 3800, lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS /�� ertified copy is hereby furnished. i FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING +ertified copy is filed with a county bu'diM ADDRESS NJ on department. FIXTURE OR'ITEM' ® FEE _ LOCALITY ' �� D,t - AppliSatir t", WATER CLOSET 3 NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROS5 ST. COMPENSATION INSURANCE OWNER _/wc action need.not be completed If the work Involved by MAIL SHOWER rmit Is for one hundred dollars $100 or less. ADD J ( �e_�x_r\. � (� � ( ) ) ' LAVATORY ADDRESS that in the performance of the work for which this is Issued,I shall not employ any person In any manner SINK p CITY i Z C�A TEL. NO. t cm become subject.to the Workers'Compensation La s. DISHWASHER. CONTRACTOR n + k� F5- LOL. Applicant ( 1 CLOTHES WASHER TO APPLICANT: If, after making this Certificate of ADDRESS Ion, you should. become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL, O. i nsation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM mply with- such provisions or-this permit shall.be STATELIC. C-3 � t d revoked. - ' WATER HEATER L,\& / �. LICENSE NO. �JZ�Lk CLASS ,. LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY a affirm that.I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS + 14V ncing with Section 7000)of Division 3 of the Business OUTLETS OVER fessions Code,and my license is in full force and effect. 5 PER SYSTEM- FINAL VALIDATION .�BALI C �^ 1 DATE Number Lic. Class l+ [c ^�� ' ff t FINAL for '!1• 4 �tU'1h Date l �S 4Z %"�' im BY t 0 am exempt under Sec. W t3P.C. for this reason. n. Plan check fee d/ . lop �� �Date: ++ r�Z �� ignature 1 '1 11 `�.� PLUMBING PERMIT ISS41NG FEE$ , -o-Jd"vim.-----�� TOTAL FEE ' Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name affirm that I am exempt from the Contractor's License Address the following reason (Section 7031.5, Business and ons Code): City Tel. No. ::. as owner of the property, will do the work and the tructure is not intended or offered for saleSection ''� eIL ( t - = -- 044, Business and Professions Code). CONSTRUCTION LENDING AGENCY y affirm that there is a construction lending agency for ormance of the work for which this permit is Issued .97, Civ. C.:). CZ s Name _ }- =1 [.�E s Address =;C- _ y,M1i-'5 that I have read this application and:state that the information is correct. I agree to comply with all County ices and State laws regulating Plumbing, and hereby ze repre$entatives of this County to:enter upon the mentioned'property for inspection,purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE' No r,%> re'of Permittee Date COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0402060003 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 DUPLICATE PHONE: (626) 285-0488 EXT: GAL I FEES PAID BUILDING DRESS: ON FILE 5701 ROSEMEAD BL FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LAS TUNAS 5397-012-043 OW PLANCHECK FEE 0.00 440.22 THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY 01 PERMIT ISSUANCE FEE 27.75 TENANT: 05 BACKFLOW DEVICES) 2.00 DEV 32.40 ISSU ON: PROCESSED BY: EXPIRES ON: APPLEBEE'S 13 DISHWASHERS) 1.00 FIX 16.20 02/11/04 VG 08/09/04 17 FLOOR DRAINS) 8.00 FIX 129.60 OWNER: TEL. NO: 19 FLOOR SINKS) 16.00 FIX 259.20 FINAL DATE FINAL BY: CODE: CALAC INVESTMENT - 21 HOSE BIBB(S) 3.00 FIX 48.60 3709 23 INTERCEPTOR(S) 1.00 SYS 16.20 SAN DIEGO, CA9211137 25 LAVATORIES/SINKS 13.00 FIX 210.60 DESCRIPTION'OF WORK 29 ROOF DRAIN(S) 4.00 FIX 64.80 PLUMBING ON T.I. FOR RESTAURANT 41 TRAP PRIMERS) 2.00 SYS 32.40 APPLICANT: . NO: 45 WATER CLOSET/URINAL 8.00 FIX 129.60 CHARLES RAMM - 47 WATER HEATER(S) 1.00 WTH 16.20 49 WATER TREATING EQUIP 1.00 SYS 16.20 SPECIAL CONDITIONS: 51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20 52 ADDN OUTLETS > 5 7.00 OUT 29.40 55 GAS METER (PRIVATE) 1.00 MET 16.20 CONTRACTOR: TEL. NO: 56 GAS REGULATOR 1.00 REG 16.20 APPROVALS DATE INSPECTOR SIGNATURE CLARK CONTRACTORS, INC. (949) 581-6577- 65 WATER PIPING 2-3 IN 1.00 LIN 50.55 19651 DESCARTES LIC. NO TOTAL FEES 1,568.52 UNDER SLAB WORK / FOOTHILL RANCH, CA 92610 570943 B /` G/ WATER SERVICE ' PLASTIC Y/N METAL Y/N ARCHITECT OR ENGINEER: TEL. NO: CHARLES RAMM ASSOCIATES (949) 362-1986- ROUGH PLUMBING Cf 27111 ALISO CREEK RD #195 LIC. NO: ALISO VIEJO, CA 10352 GAS PIPING GAS E T OT WATER HEATER LUMBING FIXTURES LAWN SPRINKLERS GAS TEST ILITY COMPANY NOTIFIED C GRAY WATER SYSTEM REPORT ID: DPR263 ROUTE TO: BS0508 ION WORKER'S I have a certificate of consent to 76AS66DPW9/89 APPLICATION FOR PLUMBING PERMIT 76A667A I hereby affirm that I have a certificate of consent to self insure, or a ceralficate 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. _ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS UILDING �')© (j L�LJA, ❑ Certified copy is filed with the county building InspsctIon department. NUMBER FIXTURE OR ITEM @ FEE �-��) LOCALITY CA Date I�- - Z Applica t ' , WATER CLOSET )� CROSS ST.NEAREST LV- CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB ASSESSOR COMPENSATION INSURANCE MAP BOOK PAGE PARCEL (This section need not be completed If the work involved by the SHOWER permit Is for one hundred dollars($100)or less.) LAVATORY / OWNER C'o ` I certify that in the performance of the work for which this permitC)nrAIL 1`> e� is issued, I shall not employ any person in any manner so as to 2 SINK del" ADDRESS0 )� � -\i3o - become subject to the Workers'Compensation Laws. DISWASHER CITY TEL.NO. a .9= Date 4 ,�a CLZ ApplicantCLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR .{ v e U vn Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code,you must forthwith comply with such ADDRESS15� l� ?GJ'Ec�;c� �,=c provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM tz�y1 LICENSED CONTRACTORS DECLARATION CITY �" r- TEL.NO. a Z oo } I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER l�5} ^ ' 'Z�D a V(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS CENSE NO.SZS 14C kLA CLASS Professions Code,and my license is in full force and effect. ?� GOUTLETS OVER DISTRICT NO. PROCESSED BY 13:License Number. v Z Lic.Class J 5 PER SYSTEM 6 Z�JFINAL U �', ��,�� DATE �Z—� ��+ G VALIDATION a Contractor 1 '�"�`'Q- Date 1 C.— eZ Vo ❑ FINAL I am exempt under Sec. BY B.&P.C.for this reason Date: Plan check fee ' Signature�� t PLUMBING PERMIT ISSUING FEE$ o���`J ❑ TOTAL FEE �i � `r=07 _ l�h°O`'I Plan check applicant 1 t t:"' SINGLE FAMILY f q r1 HOME OWNER-BUILDER DECLARATION Name 1 )2� �`,, TC-17 N— 11.2 60 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): � r•• t.-� °CICI ❑ a Z�nS o•l�i :��x� I,as owner of the property,will do the work and the structure Clty .p!, L Vq- Tel.NJ. Is not intended or offered for sale(Section 7044, Business and Professions Code). ® '-a { CONSTRUCTION LENDING AGENCY ? �(�(�1�)°°4`t' 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.) L t Lender's Name 7�\►", I Z Lender's Address 1�4 w. ,A I certify that I have read this application and state that the above Information Is correct. I agree to comply with all County ordinances 01111. and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned prop t for inspact' Aur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE