HomeMy Public PortalAbout5919 ROWLAND AVE_Plumbing__ /�.. ,�jvZQRKERS'COMP.ENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
Jr.ht�6by afjfirm chat I have a certificate of consent to self 76A667A
ijnsure,or 4 certificate of VVorkers'Compensation Insurance, CE 817(REV. 10/81)
or a certified.copy th.ireof'(Sec. 3800; Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company )
Certified copy is hereby furnished. j '
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING-
Certified
UILDING
Certified copy is filed with the county building inspec- ! ADDRESS..r� G�l✓C/ /CJd1
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Appligant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS.' ! BATH TUB CROSS ST.X,%—r
COMPENSATION INSURANCE OWNER
N i; SHOWER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY �� ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK A. tq CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
! CONTRACTOR
Date Applicant. CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, "after making this Certificate of �/v /�
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL.NO.
with comply with such provisions or this permit shall be J STATE D LIC.
deemed revoked: WATER HEATER LICENSE NO. 012 0 10 CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS n
(commencing with Secfion 7000)of Division 3 of the Business P OUTLETS OVER IJ
and Professions Code,and m license is in full force and effect. 5 PER SYSTEM CL
Y FINAL � � VALI ATION CL
DATE �
License Number Lic. Class
FINA 09
Contractor A/e/ 0 Lid. r� Date. BY
❑ I am exempt under Sec. tie
BAP.C. for this reason H
Plan check fee
D te: PLUMBING PERMIT ISSUING FEE$
Signa u.re
TOTAL FEE J 4(y 4-A
Plan check applicant '{ 0 0 0 0 0 5
• SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name ���. 0 - 4050
i hereby affirm that I am exempt from the'Contractor's License
Law for the following reason (Section 7031.5, Business and Address �� 0 0 0 [( Q 5
Professions Code): CityTel. No. — 1, 14-85
❑ 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 th! application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authoriz re resentatives of thi County to enter upon the
above- a oned property, r i•sp ction Our oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1112140028
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS:
ITR: 6561 LT: 37 1 ] 5919 ROWLAND AV
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:I TEMP CA 917802241 I
(ASSESSOR INFORMATION NUMBER: I NEAREST CROSS STREET:
18587-031-008 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY, Cl
I 113 DISHWASHER(S) 1.00 FIX 16.30 1 I
ITENANT: 125 LAVATORIES/SINKS 2.00 FIX 32.50 11SSUED ON: PROCESSED BY: PLAN BY:
I 147 WATER HEATER(S) 1.00 WTH 16.30 12/14/11 SR
I TOTAL FEES 92.90
(OWNER: TEL. NO: 1 [FINAL DATE FINAL BY: CODE:
IDLCC CORP. (626) 575-8880- I
19531 GIDLEY AVE. [ I �/J
ITEMP 917802241 [ IDESCRIPTION OF WORK 1
[ IREPLACE DISHWASHER, SINK, LAVATORIE AND WATER HEATER [
[APPLICANT: TEL. NO: ]
1WU, JACK (626) 523-5819- [
9531 GIDLEY AVE. [ ISPECIAL CONDITIONS: I
]TEMPLE CITY CA 91780 [
ICONTRACTOR: TEL. NO: [ ]APPROVALS DATE INSPECTOR SIGNATURE [
IT C PAINTING, INC. (626) 282-5095- 1 1 I
1514 S HIDALGO AVENUE LIC. NO [ [UNDER SLAB WORK ] I I
1ALHAMBRA CA 91801 803169 B ] I [ [ I
I I IWATER SERVICE I I I
I I IPLASTIC YIN METAL YIN
[ARCHITECT OR ENGINEER: TEL. NO: [ I [ [ I
I - I IROUGH PLUMBING
[ LIC. NO: [ I I
I
1 [GAS PIPING
I [ IGAS VENT
[ I IHOT WATER HEATER I I I
I I IPLUMBING FIXTURES [ [ [
I I I
I I [LAWN SPRINKLERS I I ]
I I I
] I (GAS TEST 1 [ I
I (UTILITY COMPANY NOTIFIEDI I I
I I I� I I I
1 I IGRAY WATER SYSTEM
I I I
I I I I I I
I I 1 I I I
I [ I I I I
I IREPORT ID: DPR263 ROUTE TO: BS0508 I I I [
I I I I I I