HomeMy Public PortalAbout5827 ROSEMEAD BLVD_Plumbing__ WORKEF MPENSATION DECLARATION 6 DPW.4/87 APPLI♦ AN FOR PL MBING E MIT L
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hereby, affirm t ave a certlhcate of consent to self in 76A667
sure,or certifica.__. .Vorkers'Compensation Insurance,or a CE 817(REV 8/86) �1� ' ri'Y .► I I
certified copy thereof(Sec. 3800, Lab. C.) v u
Policy No.73 iiaG QOFlompany NATION W 1171✓ COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE)
dCertified copy is filed with the county building inspection ADDRESS 14, pose m6AJ3
department. t NUMBER FIXTURE OR ITEM @ FEE
LOCALITYLF—
Cml
Date— 00'�S�91 Applicant - WATER CLOSET(TOILET) 10 NEAREST
CERTIFICATE OF EXEMPTION.FROM ORKE S'
BATH TUB CROSS.ST,
COMPENSATION INSURANCE OWNER SHOWER G RAM V! O
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS 7iOO t0(raVW (Z
I certify that in the performance of the work for which this per- SINK q ^
Y P Y N Q CITY or4a TEL.NO.
per-
mit is issued, I shall not employan person in an manner so �
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR U�. I i� � ��
Date ' Applicant CLOTHES WASHER ADDRESS-164,2 516 .� �V��
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL'RECEPTOR
emption,you should become subject;to the Workers'Compen-
CITYV� TEL.NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM ���'� 3
ly with such provisions or this.permit shall be deemed revok- STATE ,�{{ Q LIC.
ed. WATER HEATER LICENSE NO. �'� ` —4 `I-1 CLASS C
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
1 hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
feet. G^3(d I 11 ATS- 000 DATE ��t b a O
License Number Lic. Class
AL
Con.tioctor Date— j'cl BY O
I amexempt undef ec. W
B.&P.C. for this reason V pop.• Plan check fee
Date: M
, PLUMBING PERMIT ISSUING FEE$ ` 0 t
Signature
• TOTAL FEE .J
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant -
I hereby affirm that I am exempt from the Contractor's License Name iP liV 3t �� .0 A
Law for the following reason (Section 7031.5, Business and - f' �'I°4
Professions Code): Address IS42 Se i j!,WCeWT A Up 330? j- j
• lyi 1 y Y Li-
I, as owner of the property, will do the work and the City t.0PJC:„ I3a5%C* C Te. o. .4qq.-k-36, 1 IT ENS
structure is not intended or offered for sale(Section 7044, _ s K
Business and Professions Code). I;{A . .,.e:a m 30-
CONSTRUCTION LENDING AGENCY ► CHECK 5 5.311 E
I hereby affirm that there is a construction lending agency for r i-
the performance of the work for which this permit is issued CHANGE °i`l`l
(Sec. 3097, Civ. C.).
Lender's Name T0KA1 IbAf314-- OF' CAIAFoam 1A 1;11;lju—UUIj1
Lender's Address 534- Wi Cr", ST, . Llec C.A Q� li` 1 A.I
I certify that I have read this application and state that the
above information is correct. I agree to comply with'611 County
ordinances and State laws regulating Plumbing, and hereby '
N authoriz this County lo. enter upon the
ab -mention r inspection purposes.
�d'2� � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa ure o Permi ere Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0806160015
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 5827 ROSEMEAD BL [
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:[ TEMP CA 91780 I
[ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: LAS TUNAS [
15397-012-043 101 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY, Cl
1 125 LAVATORIES/SINKS 2.00 FIX 32.40 I
ITENANT: 145 WATER CLOSET/URINAL 2.00 FIX 32.40 [ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
IAT & T STORE 147 WATER HEATER(S) 1.00 WTH 16.20 106/16/08 SR 12/13/08
1 160 DWV REPAIR OR ALTER 1.00 SYS 16.20 1 I
(OWNER: TEL. NO: 1 TOTAL FEES 124.95 IFINAL DATE FIN BY: CODE: 1
ICINGULAR WIRELESS (719) 439-6304- I 1 I
11360 HAZALINE LAKE 1 I� I
ICOLORADO SPRINGS I IDESCRIPTION OF WORK II
I I ITENANT IMPROVEMENT WORK PLUMBING
[APPLICANT: TEL. N0: I [
IKAMUS & KELLER ARCHITECTS (562) 216-5244- 1 1
100 W. BROADWAY I ISPECIAL CONDITIONS:
LONG BEACH CA 90802
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ICONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE I
IMENEMSHA DEVELOPMENT GROUP (310) 343-3430- 1 1 [
14950 W. 145TH ST. LIC. NO I (UNDER SLAB WORK I [ 1
HAWTHORNS, CA 90250 647870 B i iWATER SERVIC1-1
E 1 1 1
1 [PLASTIC YIN METAL YIN [ I 1
(ARCHITECT OR ENGINEER: TEL. NO: [ I [ I I
IKAMUS AND KELLER ARCHITECTS (562) 216-5244- 1 IROUGH PLUMBING I 1 [
1100 W. BROADWAY STE. 6015 LIC. NO: I I 1 [ 1
]LONG BEACH, CA 90802 C20397 I IGAS PIPING I I
GAS VENT
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I I IHOT WATER HEATER I I 1
I I IPLUMBING FIXTURES I I 1
ILAWN SPRINKLERS I I 1
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I 1 IGAS TEST I I
I 1 ]UTILITY COMPANY NOTIFIEDI
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IGRAY WATER SYSTEM I [ 1
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IREPORT ID: DPR263 ROUTE TO: BS0508 1 1 1 1
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