HomeMy Public PortalAbout6214 ROWLAND AVE_Plumbing__ WO WERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
�•1 i ert'by2 affirm that I have a certificate of consent to self in- 76►667A °� 4/87
say' of a certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86)
cQ'rtiiied copy thereof(Sec. 3800, Lab. C.)
Poli No. (ObS2� Company S "`-A t E�,n i COUNTY OF LOS ANGELES I DEPT. OF PUBLIS WORKS.',
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
❑ Certified copy is filed with the county building inspection ADDRESS ( ld tj
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY'
Mote C
Date ItR)I13S Applicant d. WATER CLOSET(TOILET) NEAREST `
CERTIFICATE OF EXEMPTION FROM WO KERS'
BATH TUB CROSS ST. Zny^
•COMPENSATION INSURANCE i SHOWER / OWNER TPV IL
(This section need not be completed if the work involved by G MAIL
the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS j
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any persori in any manner so SINK CITY �/► t TEL. NO.j Q`� /pl b
I
CONTRALTO
as to become subject to the Workers'Compensation Laws. DISHWASHER y V t ILV P$ elks '`-�+t3 b
Date Applicant CLOTHES WASHER ADDRESS g
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM (�$Z i 1
ly with such provisions or this permit shall be deemed revok- STATELIC.
ed. WATER HEATER LICENSE NO. L_ja CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROC Y
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ��
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINALAQ 6 VALID N
fect. DATE -� O
License Number L•td (1(� Lic. Class U
- FIN
Contractor Date t BY O
0 I am exempt unher Set.- W
B.BP.C, for this reason
Plan check fee ® �9 6 2 0 A
Date: PLUMBING PERMIT ISSUING FEE$ #.0 0 0 0 0 5
Signature TOTAL FEE •l1 0 °. 650
SINGLE FAMILY Z10 1,� o 0 o.1 6505
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name Q 5 9 7-8 8
Low for,the following reason (Section 7031.5, Business and
Professions-Code): Address
I, as owner of the property, will do the work and the City Tel. No.
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 lop
ordinances and State lows regulating Plumbing, and hereby I
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
i_ .I - SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitt a l6atel
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0312150004
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL D: FEES PAID BUILDING ADDRESS:
TR: 18002 LT: 9 6214 ROWLAND AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801724
ASSESSOR-INFORMATION UMBER: NEAREST CROSS STREET: GARIBALDI
5385-024-027 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY
07 BATHTUBS/SHOWERS 1.00 FIX 16.20
TENANT: 11 CLOTHESWASHER(S) 1.00 FIX 16.20 ISSUED ON: PROCESSED BY: PLAN Y: P RES ON:
13 DISHWASHERS) 1.00 FIX 16.20 12/15/03 JK 06/12/04
21 HOSE BIBB(S) 1.00 FIX 16.20
OWNER: TEL. NO: 25 LAVATORIES/SINKS 4.00 FIX 64.80 FI W D�1�E L� FINAL BY: CODE:
DAY STEVEN A (626) 286-6016- 45 WATER CLOSET/URINAL 1.00 FIX 16.20
6214 ROWLAND AV 47 WATER HEATERS) 1.00 WTH 16.20 r�
TEMP 917801724 51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20 DESCRIPT ON OF WOR
60 DWV REPAIR OR ALTER 1.00 SYS 16.20 PLUMBING FOR ADDITION/REMODEL
TOTAL FEES 222.15
APPLICANT: TEL. NO:
SAME AS OWNER (310) 273-0220-
SPECIAL CONDITIONS:
MIKAELA NAGLER
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER
LIC. NO UNDER SLAB WORK
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: TEL. NO:
ROUGH PLUMBING /A
LIC. N0: V
GAS PIPING T-
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES
LAWN SPRINKLERS
GAS TEST
UTILITY COMPANY NOTIFIED
CW
GRAY WATER SYSTEM
REPORT ID: DPR263 ROUTE TO: BS0508