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WORKER'S COMPENSATION DECLARATION20-0028�ADPw9;B9 APPLICATION FOR PLUMBING PERMIT
•"T'herSby affirm•dhat I have a certificate of consent to self Insure, •
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.)
Policy No. Company
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
'
❑ Certified copy is hereby furnished. I
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
DRESS D.� � '{.��A-)
E] Certifiedcopy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM @ FEE
_ LOCALITY
Date Applicant ® WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB / CROSS ST. /r} Stq
ASSESSOR .f
COMPENSATION INSURANCE
(This section need not be completed if the work Involved by the / SHOWER MAP BOOK S PAGE J 3 PARCEl��3
permit Is for one hundred dollars($100)or less.) OWNER ���� �cGA�Q b
I certify that in the performance of the work for which this permit LAVATORY �j/
Is Issued, I shall not employ an y SINK ADDRESS J�m
p y y person in an manner so as to
become subject to the Workers'Compensation Laws.
A DISWASHER CITY TEL.NO.
Date l' /� Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, aft ak ng his Certificate of CONTRACTOR�� �jt� �B '�� Co
,
Exemption,you should become subJ to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code,you must forthwith comply with such ADDRESSjo
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION ` C L� C_%T TEL.t � >
I hereby affirm'that I am licensed under provisions of Chapter 9 ® WATER HEATER J CL
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS IL CENSE NO. `�/ CLLA•SS
Professions Code,and my license is in full force and effect.
OUTLETS OVER DISTRICT a/� PROCESSED BY
7k/� 5 PER SYSTEM
License Number a 7
Lic.Class I=
DATE FINAL ?_ 1 TAVALIDATION
Contractor—°�° ��A� S Data��� s
LLi
AL
F1I am exempt under Sec. Q BY
B.&P.C.for this reason
ate:
Plan check fee Al
®.
Signature
PLUMBING PERMIT ISSUING FEE$ 112
_
TOTAL FEE ' . j/ • D 1 TEHIS
• ❑ Pian check applicant '
SINGLE FAMILY CCC 1.2 c C)6
HOME OWNER-BUILDER DECLARATION Name •i aWCK 11�24�
I hereby affirm that I am exempt from the Contractor's License Law Oft
for the following reason (Section 7031.5, Business and Professions Address
�/7 °
Code):
❑ City Tel.No. CHANGE
1,as owner of the property,will do the work and the structure
is not intended or offered for sale(Section 7044, BusinessOOM
and Professions Code). ® �yy� �f � gti
CONSTRUCTION LENDING AGENCY �L�ppM Ai'I 9:3-
1 hereby affirm that there is a construction lending agency for the r
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 ou to enter upon the above-mentioned
property for• ;ctf* as. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sienat of Pe ittaa Da4a
D.U.H.17 SEM BErH 1-48 ~ �� APPLICATION FOR PERIM
DEPARTMENT OF BUILDING AND ,SAFETY
COUNTY OF LOS ANGELES �L�����G 7
WM.J.FOX.CHIEF ENGINEER
NATURE OF INSTALLATION DISTRICT tio.. GROUP ZONE
e�P NO.
ROUGH FIXTURESCOMPLETE ✓ � �' / d
HEATER CESSPOOL. HISIMPTIC TANK RECEIVED BY READY-FOR DATE 188UED. _
AS• M ISCELLAN FIRST INSPECTION
APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY
RING & €�.EG1fRfC CE.ADDRESS /
K NAME
hl
m ADDRESS LOCALITY // d,4 PSG/
NZAREPT
JZ _
6
CITY L.�e2 NO .X2_7 l 9 CROss sr. �.�
COUNtv
CERT.No. EXPIRES&"-3d
�' NAME
LOCATION OF SEPTIC TANS, OR CESSPOOL Z MAIL
NORTH O ADDRESS
CITY TEL.No..
I AM THE LEGAL POSSESSOR OF THE .ABOVE LOS
ANGELES/1OUNTY CERTIFICATE OF-QUALIFICATION
6/11 .
' NBBR
1 AM THE LEGAL OWNER OPERTY DESCRIBED-
ABOVE.
OWNER
CORRECT[ONS
SOUTH J
DESCRIPTION OF WORK.
a
) z_
_BATH TUB FURNACE 0
tY
ROWER DISHWASHER p
*AVATORV REFRIGERATOR
ICITCHEN SINK WATER SOFTENER
FLOOR SINK SAND TRAP
LOP SINK FLOOR DRAIN
WASH TRAY URINAL APPROVALS
WATER CLOSET DRINKING FOUNTAIN TB' �wePseTOR•s NANS
l WATER HEATER DENTAL LAVATORY ROUGH PLUMBING
' "Mr-LIS-2-GAS SODA FOUNTAIN
OUTL GAS PIPING
GAS VENT I I I
s, CESSPOOL I I
TOTAL NUMBER OF FIXTURES .! U SEPTIC.TANK I
CESSPOOI SEPTIC TANK SEWER I
$ UTILITY CO.NOTIFIED.I I
TOTAL.FEE
0 FINAL I �/JGSI' �y
Y
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1111150011
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS.
[TR: 10821 LT: 9 BL: .001 I 5030 RYLAND AV
[FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917804038
ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: LOWER AZUSA
18585-013-003 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: B4 LOCALITY: TEMPLE CITY
160 DWV REPAIR OR ALTER 4.00 SYS 65.10
(TENANT: I TOTAL FEES 92.90 JISSUED ON: PROCESSED BY: PLAN BY:
111/15/11 SR
OWNER: TEL. NO: [ [FINAL DATE FINAL BY: CODE:
GUARD JENNIFER M (626) 448-0680-
15030 RYLAND AV [ [
[TEMP 917804038 [DESCRIPTION OF WORK [
I [ [EXTEND PLUMBING VENTS TO NEW ROOF
I
[APPLICANT: TEL. NO: [ I [
[DANNY CHAAYA (310) 210-2510- [ I [
[PO BOX 46341 0 [SPECIAL CONDITIONS: [
[LOS ANGELES 90046 [ [
[CONTRACTOR: TEL. NO: I [APPROVALS DATE INSPECTOR SIGNATURE
I
[TIP-TOP BUILDERS (877) 842-8220- I I I
17256 BELLAIRE AVE. LIC. NO [ [UNDER SLAB WORK [ I I
[NORTH HOLLYWOOD NONE I I
I [ [WATER SERVICE
I [ [PLASTIC Y/N METAL Y/N [ [ [
[ARCHITECT OR ENGINEER: TEL. NO: [ I [ [ [
I - [ [ROUGH PLUMBING
[ LIC. NO:
1 I [GAS PIPING I I
I I IGAS VENT I I I
I I [HOT WATER HEATER I I
I I [PLUMBING FIXTURES 1 I [
I I [LAWN SPRINKLERS
I I I
1 IGAS TEST 1-1 I
I [UTILITY COMPANY NOTIFIED[ I [
I I ICWv I I I
[ [ IGRAY WATER SYSTEM
I I I
I I I I I I
I I I I I I
II I I I I I-
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