HomeMy Public PortalAbout5615 SANTA ANITA AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 200028 DPW 9/89 APPLICATION
��� ������®ry.� PERMIT
78A887A E u
1 hereby affirm that I have a certificate of consent,to self Insure,
or a certifica{e pf Worker's Compensation Insurance, or a certified
copy thereof(Sdc.3800,Lab.C.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No. 994965 Company RiPI N i C TnAo m!ty
❑ ertlfl.d copy Whereby furnished. ,,�"}
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 56 SANTA MITA AVENUE
UILDING
Certified copy is filed with the c unt b ing inspection n
department. afft—
.61:2/041 "/� NUMBER FIXTURE OR ITEM ® (�EEd LOCALITY
]PLE CIS
Date Appllc WATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE BATH TUB Z "7 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.) OWNER HSEN C(H CONST=ON
ag
I certify that in the performance of the work for which this permit LAVATORY
is issued, I shall not employ any person in any manner so as to �1 MAIL
SINK
become subject to the Workers'Compensation Laws. 7! ADDRESS 1300 E. MAIN STREET #j<208
DISWASHER CITY AT HANMA. TEL.NO.30&-1$2$
Date Applicant CLOTHES WASHER ; CONTRACTOR FRANK MRRONE & SONS, INC.
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS 9$60 IDWER AZUSA ROAD
provisions of the Labor Code,you must forthwith comply with such + ,
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION WATER HEATER CITY Ej; TEL.NO.444-2548 d
1 hereby affirm that I am licensed under provisions of Chapter 9 STATE LIC. (L
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS Q LICENSE NO. 397884 CLASS X/36 C/16 U
Professions Code,and my license is In full force and effect.
OUTLETS OVER DISTRICT NO. PROCESSED BY it
'��
License Number 397884 Lie.class X/36 C/16 5 PER YSTEM _ � U
DATE
FINAL y L VALIDATION a
Contrect MARR�iE & SONS I Date 12/31/94'. cli
I am exempt under Sec. FBY
INAL Z
B.&P.C.for this reason ACC 1°a
Plan check fee 315 107701
0
Date: _
PLUMBING PERMIT ISSUING FEE$ V `
Signature f`'' 1 ITEMS
TOTAL FEETOTAL 1077.00
SINGLE FAMILY
Plan check applicant `�U CHECK 1077.00
,
HOME OWNER-BUILDER DECLARATION Name 'CHANGE
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Address n
Code):
E] 1,
Tel.No. 0000-0001 9/360/93I,as owner of the property,will do the work and the structure v 1945 .1 AM10o47
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 j
I representatives of this County to enter upon the above-mentioned
'
!PMropefor Mlnsptlon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Slailiature of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1101050011
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS: [
ITR: 51173 IT: 1 UN: 2 I [ 5615 SANTA ANITA AV B
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( TEMP CA 917802970 [
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
18573-020-059 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 597 GRID: D3 LOCALITY: TEMPLE CITY, CI
1 147 WATER HEATER(S) 1.00 WTH 16.30 I I
ITENANT: ] TOTAL FEES 44.10 (ISSUED ON: PROCESSED BY: PLAN BY: [
I 1 101/05/11 SR 1
[OWNER: TEL. NO: ]i IFI AL DATE FIN CODE: ]
I LEE, JERRY - [' I ��I 1
15615 SANTA ANITA AV [ I : 1
ITEMP 917802970 15ESCRI TIO OF WORK
IREMOVE/REPLACE GAS WATER HEATER 1
I
(APPLICANT: TEL. NO: ]
IFAST WATER HEATER COMPANY (425) 636-7084-
112601 132ND AVE IISPECIAL CONDITIONS: ]
1KIRKLAND, WA 98034 1 I 1
[CONTRACTOR: TEL. NO: I [APPROVALS DATE INSPECTOR SIGNATURE 1
IFAST WATER HEATER (425) 636-7054- I 1I I 1
112601.132ND ST. LIC. NO I ]UNDER SLAB WORK
[KIRKLAND WA 98034 C36931237 I I 1 I I
I [ (WATER SERVICE
I; IPLASTIC YIN METAL YIN I 1 1
[ARCHITECT OR ENGINEER: TEL. NO: 1 I_ I I I
I - 1 ]ROUGH PLUMBING
] LIC. NO: I1 I I
1GAS PIPING 1 1
I. IGAS VENT I 1
1 IHOT WATER HEATER I I
I
1 II IPLUMBING FIXTURES
I. ILAWN SPRINKLERS 1 1 1
I I
1 ]GAS TEST I 1
I I
1 ] ]UTILITY COMPANY NOTIFIED( I 1
I I ICWvI I I
I I 1GRAY WATER SYSTEM
I I I I I I
I I I I I
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1 I I i I I
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IREPORT ID: DPR263 ROUTE TO: BS0508
I I I I I I
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS
PL 0508 1401060032
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: I FEES PAID I BUILDING ADDRESS: I
TR: 51173 IT: 1 UN: 3S615 5615 SANTA ANITA AV C
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT; TEMP CA 917802970 I
ASSESSOR INFORMATION NUMBER: I NEAREST CROSS STREET:
8573-020-060 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: D3 LOCALITY: TEMPLE CITY CAI
I47 WATER HEATER(S) 1.00 WTH 16.20
TENANT: TOTAL FEES 44.00 ISSUED ON: PROCESSED BY: PLAN BY:
01/06/14 SR
I
OWNER: TEL. NO: I 1F DATE F BY: CODE:
IDIAZ, DAVID
15615 SANTA ANITA AV
(TEMP 917802970 I IDESCRI TION OF WORK
I (CHANGE OUT GAS WATER HEATER, SAME LOCATION GARAGE 38 GALLONSI
1 I li I
(APPLICANT: TEL. NO:
IEMILY OR LUBA BATIOFF (714) 381-7974- I
I � SPECIAL CONDITIONS:
I I
(CONTRACTOR: TEL. NO: 1 (APPROVALS DATE INSPECTOR SIGNATURE
IFAST WATER HEATER CO (425) 636-7054- I 1
111715 NORTHCREEK PARKWAY SOUTH LIC. NO 1UNDER SLAB WORK I 1
(SUITE C106 987398
BOTHELL, WA 98011 IWATER SERVICE I I I
IPLASTIC YIN METAL YIN I I I
(ARCHITECT OR ENGINEER: TEL. NO: I I I
LIC. N0: I (ROUGH PLUMBING I I
GAS PIPING 1
I � I � I
IGAS VENT I I I
IHOTIWATER HEATER
I
IPLUMBING FIXTURES
I I (LAWN SPRINKLERS
I I IGAS TEST I
�DTILITY COMPANY NOTIFIED( 1
I �cwv I I I
I I 1GRAY WATER SYSTEM
j i I
I i I I
I
I � I
REPORT ID: DPR263 ROUTE TO: BS0508 I I I