HomeMy Public PortalAbout5749 ROSEMEAD BLVD_Plumbing__ WORKg )MPENSATION DECLARATION A►PPLI TION FOR PLUMBING PERMIT
hereby, affirm have a certificate of consent to self in- 20-0026
6A66 A PW 4/87
sure,or a certificu—,Workers'Compensation Insurance,or a CE 817(REV.8/86)
certified copy thereof(Sec. 3800, Lab. C.)
Policy No 13 w G w V19 pony0,,++ E COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS 7 "
F-1certifiedcopy is hereby furnished. /s1 1?lIrl
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Er Certified copy is filed with the county building inspection ADDRESS � AA"10
department. a 1 NUMBER FIXTURE OR ITEM @ FEE LOCALITY TZ M C Ci
Date ~�+Z�9 Applicant WATER CLOSET(TOILET) NEAREST A
CERTIFICATE OF EXEMPTION FROM ORI ERS'
BATH TUB CROSS ST. GAC TU PA
COMPENSATION INSURANCE SHOWER OWNERCHAM +00
(This section need not be completed if the work involved by MAIL r�
the pormit is for one hundred dollars($100)or less.) LAVATORY ADDRESS 00 ®� .(–A W cOV
I certify that in the performance of the work for which this per SINK
mit is issued, I shall not employ any person in any manner so CITY WA,44 TEL. NO.,44
as to become subject to the Workers'Compensation Laws. DISHWASHER csv–
CONTRACTOR 1 J f
, 17MWflo
Date Applicant CLOTHES WASHER ADDRES r
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR S
emption,you should become subject to the Workers'Compen- CITYr��\I TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM wp
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATERLICENSE NO. CLASS G'Ice
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter ® GAS SYSTEM OUTLETS p
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER O
fe
and Professions Code, and my license is in full force and ef-ct. U 5�PER SYSTEM 8 FINAL VALIDATION C
DATE
License Number.%S � r--5C0Lic. Clasr--5C0 �g�� O
^IA) FINAL
ContractorQ1�C_' Date BY O
I am exempt under Sec.
B.BP.C. for this reason c
Plan check fee lol
Date: PLUMBING PERMIT ISSUING FEE$
Signatu TOTAL FEE
INGLE-BU AMILY Plan check applicant
HOME OWNER-BU DER DECLARATION PP
I hereby affirm that I am exempt from the Contractor's License Name 4Suv Q 0 • -
Law for the following reason (Section 7031.5, Business and rr a
Professions Code): Addressp �L�pa 'T 1
QL I
84 Y • J-r o•�i
Cit Tel. No.
I, as owner of the property, will do the work and the Y Q��. ��)�
structure is not intended or offered for sale(Section 7044, • 13
Business and Professions Code). a 0 ® s I i I J_ �-
CONSTRUCTION LENDING AGENCY t�G'.K o-'-
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.). rI in
'JI
Lender's Name ® J5AMJ&_ of SAA-0r®"I� M`7"' r M
r r 1. f
f 1 r
Lender's Address
• eA-K e • 1 1 ~L dG
I certify that I have read this application and state that the �` .` i
above information is correct. I agree to comply with all County '
ordinances and State laws regulating Plumbing, and hereby `' r'`
authorize r s of this County to enter upon the ti 1q
�e-menti tie ty for inspection purposes. x ,
[I
irY —�� SEE REVEMErFOR EXPLANJ 'TORYUNGUAGE
Signafur of Per int.e Date
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1
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COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0807010017
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS: I
ON FILE I 1 5749 ROSEMEAD BL I
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:[ TEMP CA 91780 I
(ASSESSOR INFORMATION NUMBER: I NEAREST CROSS STREET: LAS TUNAS
5397-012-043 101 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY, Cl
I 147 WATER HEATER(S) 1.00 WTH 16.20 I I
ITENANT: I TOTAL FEES 43.95 [ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: [
I I 107/01/08 SR 12/28/08 1
1OWNER: TEL. NO: IFINAL DATE FIN Y: CODE: 1
I'1TJ CORP. (508) 390-1000- I ' s I
770 COCHITUATE RD. I I
IFRAMINGHAM, MA 01701 1 IDE CRIPTION OF WORK [
[ [ IREPLACE WATER HEATER I
(APPLICANT: TEL. NO: I [ I
1PALMORE (818) 518-3725- I I I
126901 AGOURA RD. 100 [ ISPECIAL CONDITIONS: I
CALABASAS CA 91301 I I [
I I I
ICONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE 1
IGLUCK BUILDING COMPANY (818) 880-8220- 1 1 I
126901 AGOURA RD SUITE 100 LIC. NO I (UNDER SLAB WORK I [
CALABASAS HILLS, CA 91301 503281 C36 [ I I [ [
I IWATER SERVICE I I
(PLASTIC Y/N METAL Y/N I I I
ARCHITECT OR ENGINEER: TEL. NO:
I - I IROUGH PLUMBING I I I
1 LIC. NO: I I I I I
IGAS PIPING
[ I I GAS CENT
I I I I I
I I (HOT-WATER HEATER I
[ I IPLUMBING FIXTURES I I 1
I (LAWN SPRINKLERS I
(GAS TEST [
UTILITY COMPANY NOTIFIEDI I
I I ICWv I I I
IGRAY WATER SYSTEM 1 [
I I I 1 I I
I I I I I I
I I I I I I
I I I I I
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I IREPORT ID: DPR263 ROUTE TO: BS0508 I I I I