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Home My Public Portal About5120 ROSEVALE DR_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION F R PLUMBING PERMIT Ae rD.,u,,� wot;y off,1 that I have a certificate of consent to self 76Ao67A srl re or a certificate of Workers Compensation Insurance CE 817(REV 10/BI J <�o — "A t ��Py thereof (Sec 3BD0 La C ) BUILDING AND SAFETY TQQ7�� y No�Zompony, Gt+,+./� Certified copy is hereby furnished BUILDING FOR APPLICANT TO FILL IN(PRIM OR TYPE) ADDRESS (��f Certified copy is filed with the co t b ding mspec tion deportmen NUMBER FIXTURE OR ITEM ® FEE LOCALITY C gpplmant WATERCLOSET NEAREST CERTIFICATE OF EXEMPTIO FRO ORKERS Z— BATH TUB CROSS 5COMPENSATION I SU CE OWNEstolon need not be completed the work Involved by SHOWER - i the permit Is for one hundred dollars ($100)or less) LAVATORY MAIL ADDRESS I certify that m the performance of the work for y which thismanner cja- .y TEL NO permit is issued I shall not employ any parson in any manner SINK so as to become subject to the Workers Compensation Laws DISHWASHER 1004 CONTRACTOR Date Applicant off CLOTHES WASHER ADDRESS NOTICE TO APPLICANT If after making this the Workers of SWIMMING POOL RECEPTOR Exemption you should become subject to the Worker CITY TEL NO Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be I STATE LIC deemed revoked WATER HEATER /'1 LICENSE NO CL4SS LICENSED CONTRACTORS DECLARATION !R/ DISTRICT yQ SSED BY I hereby affirm that lam licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS V ,y ' (commencing with Section 70D0) of Division 3 of the Business OUTLETS OVER V and Professions Code nd myli is in full force and effect 5 PER SYSTEM FINAL VALI ATION DATE O License r Lic Clow_ FIN �� U Contra rU�I Date r? BY ❑ I am exempt under Sec O B 8P C for this reason UW Plan check fee Date ► Signature PLUMBING PERMIT ISSUING FEE$ 264 1.2 A 5 # Plan chock applicant . ea005 HOME OWNER BUILDDERER DECLARATION TOTAL FEE SINGLE ( • • 9 4 5 0 Name 1 hereby affirm that I am exempt from the Contractor's License address • • • 94.5 0 5Law for the following reason (Section 7031 5, Busmess and Professions Code) City Tel No 01.27-87 ❑ I as owner of the property will do the work and the structure is not intended or offered for sale (Section pop70", Business and Professions Code) CONSTRUCTION LENDING AGENCY I hereby offirm 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 , I nd&r s Address I I fy that I e read this application and state that the , amforvw a is c ect I agree to comply with all County ances a ate I�ws regulating Plumbing and hereby onae rep A nta i s of this County to enter upon the mentio a pr rty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE MgTture of Per P mee k Dote WORKERS COMPENSATION coteDECLARATION corse - APPLICATION-FOR PLUMBING PERMIT J'herebys bHvm th6t I have a �enrf¢ate of consent to self 76AO67A msurp or a cernfrtote�gf Workers Compensation Insurance, CE 817(REV 10/81) er a cendted copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY �cy No#0489604 Company Continental Cas. - - - 1 -- - Cenibed copy is hereby furnished ® FOR APPLICANT TO FILL IN(PRINT OR TYPE) - BUILDING- 5120 N. ROsevale Dr. Certifiedcopy is filed with the county budding Inspec ADDRESS hd on department NUMBERFUCTURE OR ITEM ® FEE 01 LOCALITY le Cit Date 2-5-87 Applicant OWen B105. Plba- WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST COMPENSATION INSURANCE OWNER (This soca lee need not be comw plotsd If the work Involved by SHOWER 19i Owen Construction the pomsN Is for eeo hundred dollen($100)or less ) MAIL ILRESS 2035 S. Myrtle Ave. I Canty that inthe performance of the work for maich thisner fq SINK - �^ CITY Monrovia TEL N0359-3211 permit n issued, I shall not employ any person In anyy manner ) so as to become wblect to the Worker Compensation Lows DISHWASHER CONTRACTOR Owen Bros. Plumbing, Inc. Dale Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT If aper making this Certificate of 4265 N. BaIdWin Ave. Exemption, you should become wblect to the Workers' SWIMMING POOL RECEPTOR CITY El Monte TEL NO 443-0078 Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC deemed revoked WATER HEATER LICENSE NO 231 741CLASS LICENSED CONTRACTORS DECLARATIONOUTLETS DISTRICT NO ns SSED e 1 hereby affirm that 1 am licensed under provuloof Chapter 9 GAS SYSTEM , O (commencing with Section 7000) of Dlvmon 3 of the Business OUTLETS OVER and Professions Code,and my premie is In full force and effect 5 PER SYSTEM FINAL VA ATION } 231 741 C36-20 DATE O License Number Uc Class o Contractor OWen Brog. PlbB gstate 2-5-87 FI U W ❑ I am exempt under Sec - B SP C for This reason W Plan check fee pool Date cit PLUMBING PERMIT ISSUING FEE$ Z Signature � 0 6 4 8 4 A TOTAL FEE # s e s o s 5 SINGLE FAMILY Plan check applicant i • • 9--0.0.JJ D HOME OWNER BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor s License Low far the following reason (Section 703Address 1 5, Business and 0 21 0,F-87 Professions Code) Gry Tel No ❑ 1 as owner of the property, will do the work and the structure Is not Intended or offered for sole (Section , Poo Business and Professions Code) CONSTRUCTION LENDING AGENCY I hereby nffvm that there is a construction lending agency for the performance of the work for which this permit Is issued (Sec 3097 Gv C ) ` Lander s Nome Lender s Address - - - - I certify that 1 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 authorise r resentatives f this County to enter upon the _ a �ie m ed pro er r inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE .f,/l 2-5-87 ignature of Fermin Dale - __ COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS PL 0508 9807130033 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA PHONE (818) 285-0488 EXT LEGAL ID FEES PAID BUILDING ADDRESS: SK 60 PG 55 PC 2 5120 ROSEVALE DR FEE DESCRIPTION QUANTITY LION. AMOUNT TEMP CA 917803300 ASSESSOR INFORMATION NUMBER NEAREST CROSS STREET 8585-007-065 01 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE. 597 GRID 84 LOCALITY TEMPLE CITY 07 BATHTUBS/SHOWERS 1 00 FIX 16 20 TENANT TOTAL FEES 43 95 ISSUED ON PROCESSED BY PLAN BY EXPIRES ON 07/13/98 UT 07/13/99 OWNER TEL NO FI NAL DATE FINAL B ARJOMANDI ABDOLLRAHMAN 000 - �-,7 1Q A, 5120 ROSEVALE DR / (/ TEMP 917803300 6ESCRIPTIUM UtWUNK NEW BATH TUB APPLICANT- TEL NO ERIC TELLESON CONST (626) 441-6388- 611 FAIRVIEW SPECIAL CONDITIONS SO PASADENA, CACONTRACTOR TEL _ C� APPROVALS DATE INSPECTOR SIGNATURE' (� ERIC (818) 441-6388- Ay'\ 611 FAIRVIEWAIRVIEW AVE LIC NO 1 � LINDER SLAB WORK SO PASADENA CA 91030 603508 8WATER SERVICE 1 1� PLASTIC Y/N METAL Y/N ARCHITECT OR ENGINEER TEL NO LIC NO LI3-I \��I ^ `1 �i GAS PIPING GAS VENT PLUMBING FIXTURES LAWN SPRINKLERS GAS TEST CWV �S tvlce gh j REPORT ID. DPR263 ROUTE TO BS0508