HomeMy Public PortalAbout5503 SANTA ANITA AVE_Plumbing__ 1` WORKER'S COMPENSATION DECLARATIONBA PW9le9
=BAPPLICATION FOR PLUMBING PERMIT
I hereby ftrm'that I have a-certificate of consent to self insure, /'1 6. C�/'�'® C / �iNY� PERMIT
or a certif�of Worker's Compensation Insurance, or a certified
copy thereof Sec.3800 Lab.C.) ^` '
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No. Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
ADDRESS
❑ Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM @ FEEy�r
LOCALITY .��• �,� C C/
Date Applicant WATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS T.
COMPENSATION INSURANCE I ASSESSOR
(This section need not be completed If the work involved by the SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) LAVATORY OWNER
I certify that in the performance of thelwork for which this permit MAIL
is issued, I shall not employ any person in any manner so as to SINK ADDRESS
become subject to the Workers'Compensation Laws. [� p
//� / �� DISWASHER CITY TEL.NO'7 YJ
Date `1// rAppiicant V CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT: If, afte making this Certificate of
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR �/ s
provisions of the Labor Code,you must forthwith comply with such ADDRESS Q
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM / �J 9
LICENSED CONTRACTORS DECLARATION W%►TER HEATER CITY/. TEL.NO.,f'� r � a
I hereby affirm that I am licensed under provisions of Chapter 9 o� /
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS IL CENSE NO. �o�` v� CLA38 e:R V
Professions Code,and my license is in full force and effect. ,
OUTLETS OVER DISTRICT NO. PROCESSED BY +CC
5 PER SYSTEM1 , D,Q Q
License Number (l Lic.Class U
FINAL (V1J
DATE &JQATION n.
Contractor Date coo
❑ I am exempt under sec. i el SI� T4TAL ITEMS 4�� �
B.&P.C.for this reason
Data. Plan check fee
i PLUMBING PERMIT ISSUING FEE$ Q ® � 43.4
Signature
TOTAL FEE
Plan check applicant191
SINGLE FAMILY AT
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5, Business and Professions Address
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 authorize
representatives of this County to enter upon the above-mentione
SEE REVERSE FOR EXPLANATORY LANGUAGE
property for Inspection purposes. J/i �'�
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1304240038
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS:
IBK: 67 PG: 49 PC: 2 I 1 5503 SANTA ANITA AV
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:] TEMP CA 917802905
ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: DAINES
18573-020-039 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 597 GRID: D3 LOCALITY: TEMPLE CITY CAI
1 107 BATHTUBS/SHOWERS 1.00 FIX 16.20 1 ]
TENANT: I TOTAL FEES 44.00 (ISSUED ON: PROCESSED BY: PLAN BY:
J 104/25/13 SR 1
(OWNER: TEL. NO: I IFI DATE FIN23L BY: CODE:
ISHAH, MEHUL (626) 279-6424- I 1
15503 SANTA ANITA AVE I I
ITEMPLE CITY CA 91780 I IDESCRIPTION OF WORK ]
I i (SHOWER ONLY
(APPLICANT: TEL. NO: I I I
ISAME AS OWNER
SPECIAL CONDITIONS:
I
ICONTRACTOR: TEL. NO: I ]APPROVALS DATE INSPECTOR SIGNATURE ]
ISAME AS OWNER - I I ]
I LIC. NO I (UNDER SLAB WORK I I ]
1 1 ]WATER SERVICE 1 I
] I IPLASTIC Y/N METAL Y/N
(ARCHITECT OR ENGINEER: TEL. NO: I I I 1 1
- I IROUGH PLUMBING I
LIC. NO:
1 I IGAS PIPING
GAS VENT 1 1
J i HOT WATER HEATER I I I
J I IPLUMBING FIXTURES J ] ]
I ] (LAWN SPRINKLERS I I ]
1 J (GAS TEST
] I JUT LITY COMPANY NOTIFIED( I 1
J I CWV I I I
GRAY WATER SYSTEM
I I
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J I I I I I
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IREPORT ID: DPR263 ROUTE TO: BS0508 J ] I I
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