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Home My Public Portal About6404-6414 ROSEMEAD BLVD_Plumbing__ �y WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT t hereby o%irm that I have a certificate of consent to self 76A667A insole, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified/�opy thereof (Sec. 380Q. a/bf.pC.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N- — company- Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS L,1/ C� L/ Certified copy is filed with the county building inspec- / tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date��_ Applicant WATER CLOSETrA NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB ✓ CROSS ST. COMPENSATION INSURANCE OWNER / (This section need not be completed if the work involved by MAIL SHOWER the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS lil,1 I certify that in the'performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY v TEL. NO. so as to become subject to the Workers Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR �� Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY 73 NO. with comply with such provisions or this permit shall be STATE �,�/i LIC. l deemed revoked. O U CLASS WATER HEATER LICENSE NO. 3 LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 3 GAS SYSTEM OUTLETS d r (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAVALIDATIONt DATEf////f e 0 License qumbe �/ Lic. Class ? � 6 � jc 3 FIN 0 Contracto � Dote /—ZO BY r � ❑ I am exempt under Sec.' B.&P.C. for this reason Plan check fee pol Date: PLUMBING PERMIT ISSUING FEE$ (� Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name Q Q 2 j A I hereby affirm that I am exempt from the Contractor's License '' c c o Law for the following reason (Section 7031.5, Business and Address Professions Cit:Code) y Tel. No . 1, as owner of the property, will do the work and the structure is not intended or offered for sale (Section , P^t 5-a C 7044, Business and Professions Code). OAC CONSTRUCTION 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's Name Lender's Address I certify that I have 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 bove-mention%pd prioperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 3 Sign t re of Pe mittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT s' I hereby affirm that I have a certificate of consent to self 76A667A �insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) �. or'a certified copy thereof (Sec. 38 b. C.) COUNTY OF LOS ANGELES r / BUILDING AND SAFETY Policy 0:0P 3o Compan-� Gri ❑ Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS CA Certified copy is filed with the county building inspec- tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY � WATER CLOSET G Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESSd I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO / 2J so as to become subject to the Workers'Compensation Laws. DISHWASHER G v (GUr CONTRALTO - Date Applicant CLOTHES WASHER ADDRESS q� NOTICE TO APPLICANT: If, after making this Certificate of /7G Gl Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY TEL. LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE �iQ��` LIC �9 . deemed revoked. WATER HEATER. �— LICENSE NO. 7p(J 7 CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ' v $' and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINA � j d3� DATEL / Z/ VALIDATION License Number�5 v� Lic. Class� p� FINAL O Contractor l' - Date _z O BY , �D ❑ I am exempt under Sec. 9�r- IA B.&P.C. for this reason a Plan check fee Date: ,V PLUMBING PERMIT ISSUING FEE$ CJ Signature TOTAL FEE Plan check applicant - 4 0 2 6 A SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name 0 0 0 0 0 5 I hereby affirm that I am exempt from the Contractor's License Address St2 E l u 0 Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. L ? 5 C ❑ I, as owner of the property, will do the work and the t structure is not intended or offered for sale (Section Opp, f'--C 5 7044, Business and Professions Code). CONSTRUCTION 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's Name Lender's Address I certify that I have 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE � �7— P-3 Signature of Permittee Date 1� WORKERS'COMPENSATION DECLARATION i,-,/-f herby affirm that I have a certificate of consent to self 76A667A APPLICATION FOR PLUMBING PERMIT insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. El Certified APPLI ANT TO FILL IN(PRINT OR TYPE) BUILDING M Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIX URE OR ITEM @ FEE LOCALIYY GA /Y1,� WATER CLOS T �p '` ,e� IS LV � Date Applicant NEAREST `� ��,� CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. V—m COMPENSATION INSURANCE SHOWER OWNER c ML t KS (This section need not be completed if the work involved by MAIL pp ��qq� �,^ the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS l0'[ d � n�7 a L.0` I certify that in the performance of the work for which this p permit is issued, I shall not employ any per n in ny manner , SINK .® CITY 1"� TEL. NO.�' /`J—C so as to become bject to the Wore pe do ` iTv I DISHWASHER CONTRACTOR Date !� Applicant t CLOTHES WASHER ADDRESS NOTICE O A LICA T: If, after making this ertificote of Exempt''n, you should become subject ib the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY TEL. NO. with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO ROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (� ill (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER `'' 0 ", Vv S' and Professions Code,and my license is in full force and effect. 5 PER SYSTEM e� '-� iFL-00f, r DATE 2FINAL VALI TION License Number3(42.51 -7 Class FINAL Contractor Date BY ❑ 4� I am exempt under Sec. � B.&P.C. for this reason Plan check fee 211 0.5A m �_71PLUMBING PERMIT ISSUING FEE$ ► # 0 0 o 0 0 5 Signature TOTAL FEE 2, 6-0 ( o o 2 2 5 0 SINGLE FAMILY Plan check applicant o o 0 2 2 5 0 10: HOME OWNER-BUILDER DECLARATION Name 1.2 1 -8 4 1 hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). CONSTRUCTION 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's Name Lender's Address I certify that I have 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 authorizer resentotives of this County to enter upon the Aab,p8vm;Lonedcoon pur ores. �^J SEE REVERSE FOR EXPLANATORY LANGUAGE t . " Signature of Permi a t -.t e WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 1 I he4by affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof-(Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY r.., Policy No. Company Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) B<,IILDING y O Certified copy is filed with the county building inspec- ADDRESS I tion department. NUMBER FIXTURE OR ITEM @ FEE `''�'� ! LOCALITY / Date Applicant , WATER CLOSET NEAREST - CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER (This section need not be completed if the work involved by SHOWER the permit is for one hundred dollars $100 or less. MAIL p ( LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK ® CITY TEL. NO. so as to become subject to the Pebject rs ompensation Laws. DISHWASHER CONTRACTOR r� L /J Date' J pplicanCLOTHES WASHER �L NOTICE TO APPL T: If, aftjc ng t is Certificate of ADDRESS S� Exemption, you should beco the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forthCITY TEL. NO. - LAWN SPRINKLER SYSTEM / with comply with such provisions or this permit shall be STATE LICWVKX deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER "'�a and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL —/n VALI ATION 0 License Number Lic. ClassDATE (vvJ FI L Contractor Date B 1� ❑ I am exempt under Sec. ;91 28.9A B.BP.C. for this reason Plan check fee ► # a 0 0 0 0 5- o Date: PLUMBING PERMIT ISSUING FEE$ Signature `l fiy TOTAL FEE /? r✓ ( o o 2 2-5 0 SINGLE FAMILY Plan check applicant o 0 o 2 2 5 0 5 HOME OWNER-BUILDER DECLARATION Name L� LJq 1.0 2_8 5 1 hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. _3 ❑ 1, as owner of the property, will do the work and the structure is not intended or offered for sale (Section O 7044, Business and Professions Code). CONSTRUCTION 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's Name Lender's Address I certify that I have read this application and state that the Poo.above information is correct. I agree to comply with all County ordin nces and tate laws regulating Plumbing, and hereby autho i re entatives of this County to enter upon the abov -me ed 'roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE --� (' Si a ure Pe ittee D to COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0210220030 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDR SS: ON FILE 6404 6414 ROSEMEAD BL FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: SGAB CA 917751958 ASSESSOR 0 MATION NUMBER: NEAREST CROSS STREET: LONGDEN 5382-021-044 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H2 LOCALITY: TEMPLE CITY 25 LAVATORIES/SINKS 6.00 FIX 97.20 TENANT: 45 WATER CLOSET/URINAL 6.00 FIX 97.20 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 47 WATER HEATER(S) 6.00 WTH 97.20 10/22/02 JK 04/20/03 55 GAS METER (PRIVATE) 6.00 MET 97.20 OWNER: TEL. NO: TOTAL FEES 416.55 FINAL DATE FINAL BY: CODE: CHANG; LU & RAESHIAU (626) 291-2345- 1 J �� 922 PARK AVENUE / 7 ARCADIA 91007 DESCRIPTION OF WORK FIRE DAMAGE REPAIR APPLICANT: TEL. NO: ISAACS PLUMBING (714) 258-0603- 1910 E EDINGER AVE SPECIAL CONDITIONS: SANTA ANA 92705 CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE ISAACS PLUMBING (714) 258-0603- 1910 E EDINGER AVE LIC. NO UNDER SLAB WORK SANTA ANA CA 92705 429549 HIC WATER SERVICE PLASTIC Y/N METAL Y/N ARCHITECT OR ENGINEER: TEL. NO: H C HANSEN ENG (714) 573-0073- ROUGH PLUMBING 17371 IRVINE LIC. N0: TUSTIN CA 92780 3027 GAS PIPING GAS VENT HOT WATER HEATER PLUMBING FIXTURES LAWN SPRINKLERS GAS TEST UTILITY COMPANY NOTIFIED CWV GRAY WATER SYSTEM * ADDITIONAL DATA ON FILE REPORT ID: DPR263 ROUTE TO: BS0508