HomeMy Public PortalAbout5787 ROSEMEAD BLVD_Plumbing__ W,QRKERS'COMPENSATION DECLARATION �� ON FORPLUU&WG HERMIT
I hareby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 '-7 I
insure, or a certificate of Workers'Compensation Insurance, 76A667A
or a.c t'fie cjt�h reof Sepc. 38gp, La�bt�.� A � COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Polic77 ( � /dv1
Certified copy is hereby furnished,
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed With the y b it 'ng inspec- ADDRESS
do departm nt. NUMBER FIXTURE OR ITEM @ FEE �L
SS� ^ LOCALITY
Date �IJ� Applicant U WATERCLOSE7 Q NEAREST
CERTIFICATE OF EXEMPTI FR WORKERS' BATH TUB CROSS ST.
COMPENSATION UR CE OWNER QD
_
(This section need not be completed if the work involved by SHOWER MAIL
the permit is for one hundred dollars($100)or less.) 7-- LAVATORY rQ / ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner &NK 1 5 Q CITY TEL. NO.
so as to become subject to the Workers'Compensation LOWS. DISHWASHE
CONTRACTOR.
Date Applicant CLOTHES WASHER ADDRESS
NOTICE 'TO APPLICANT: If, after making this Certificate of t
SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' .n n.&*�
Compensation provisions of the,Labor Code, you must forth- CITY 'C. TEL. O�
LAWN SPRINKLER SYSTEM
with comply with ,such provisions or this permit shall be STATEJU LIC..
deemed'revoked. WATER HEATER �I �C LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION / DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS r
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER `�° �✓ ''
and Professions Code,and my license is in full force and elect., 5 PER SYSTEM FINAL VALIDATION C
DATE
License Number Lac. Class `=✓ C.
FINAL
' Contractor �/l(�'�' 0' BY In
❑ I dm exempt under Sic. ry C
LI
B.aP.c. for this re Plan check fee d a
Date: / s
PLUMBING PERMIT ISSUING FEE$ P
Signature n '
TOTAL FEE / O
'Plan check applicant
SINGLE FAMILY '
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License' Address --'"� "' '
Law for the following reason (Section 7031.5, Business and wF•r e's
Professions Code): City Tei. No. j .i.w'}:rrI
❑ I, as owner of the property, will do the work and the
.�
structure is not Intended or offered for sale (Section i iJ i 171L. a� w s' f
7044, Business and Professions Code). -?-,
CHr_L•la''
CONSTRUCTION LENDING AGENCY a% -
I hereby affirm that there is a construction lending agency for ;,.Ni-INCE
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name Il�ll_`fLILI` i -�i
Lender's Address 013-52. i Ar'{1
I certify that I have read this application and state that the
above information is co t. I agree to comply with all County
ordinances and St law regulating Plumbing, and hereby
au a epre' ntativ of this County to enter upon the
a v ntio d' rop rt or
e::��
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ature of Per a Date
COUNTY OF IAS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1306070016
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
(LEGAL ID: FEES PAID BUILDING ADDRESS:
ON FILE 5787 ROSEMEAD BL
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( TEMP CA 91780
ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: LAS TUNAS
15397-012-043 IOW PLANCHECK FEE 0.00 164.10 I THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY CAI
[ 101 PERMIT ISSUANCE FEE 27.80 I I
TENANT: 125 LAVATORIES/SINKS 4.00 FIX 64.80 JISSUED ON: PROCESSED BY: PLAN BY:
MURATA (DAISO) YOSHIHIDE 145 WATER CLOSET/URINAL 2.00 FIX 32.40 107/31/13 SR
147 WATER HEATER(S) 1.00 WTH 16.20 1
OWNER: TEL. NO: TOTAL FEES 305.30 1FMI5TE F AL BY: CODE:
ILEW (S.LEW & ASSOCIATES INC), SUSAN (858) 565-8333- 1
13709 CONVOY STREET
ISAN DIEGO CA 92111 I IDETCRfPTI011 OF WORK
ITENANT IMPROVEMENT - PLUMBING PROJECT TO CONTRUCT NEW RETAILI
ISHOP, OFFICES, STORAGE AND RESTROOMS I
APPLICANT: TEL. NO:
BLIZMAN, YOSHIKAZU (310) 768-2700-
879 W 190TH STREET I ISPECIAL CONDITIONS:
IGARDENA CA 90248
I I I I
ICONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE [
ISATOH BROTHERS INTER., INC. (310) 768-2700- I I [
879 W. 190TH #935 LIC. NO I [UNDER SLAB WORK -/!I/� [
GARDENA CA 90248 743636 * y 1
I WATER SERVICE [
IPLASTIC YIN METAL YIN I I [
[ARCHITECT OR ENGINEER: TEL. NO: I I I [
ISATOH BROTHERS INTERNATIONAL (310) 768-2700- I IROUGH PLUMBING
879 W. 190TH STREET #910 LIC. NO:
GARDENA,CA 90248 743636 B i (GAS PIPING I 1
IGAS VENT I [
I [ IHOT WATER HEATER [� I
I [ IPLUMBING FIXTURES
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[ ILAWN SPRINKLERS I [
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I I IGAS TEST I I [
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(UTILITY COMPANY NOTIFIED(
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I [ [GRAY WATER SYSTEM [ [ I
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[ I* ADDITIONAL DATA ON FILE
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1 (REPORT ID: DPR263 ROUTE TO: BS0508 [ [ [