HomeMy Public PortalAbout4923 SERENO DR_Plumbing__ 1waRinISavMPENSAn°"°`consen°o DPW 9189 APPLICATION FOR PLUMBING PERMIT
I hereby etlfrrrY th/t I have D certificate of consent to Ball Insure
oro chrtlficata of Worker s'Compensallon Insurance or a certified r
copy thereof(Sac'3800 Lab C) , I - •�+,�
• ��No company COUNTY OF LOS ANG619 DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
Certified copy is hereby hrrtxefled
' FOR APPLICANT TO FILL PI(PRINT OR TYPE) BUILpNO S �,
❑ CenXied copy refiled with the county building Inspection ADDRESS
department NUMBER FIXTURE OR RENFEE
LOCAL
OLOCALITY
Date Applicant WATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS CROSS ST74-Ck
COMPENSATION INSURANCE BATH TUB ASSESSOR Q p G
(This section need not be completed If the work Involved by the SHOWER
MAP BOOK �JO Q t PAO�/4 PARC
permit Is for one hundred dollars(111100)or lees) OWNER •1
I certify that In the performance of the work for which this permit LAVATORY - � O
Is Issued I shell not employ any person In any manner so as to91NK MAIL SG/�
became subject to the Workers Compensation Laws ' - rA.rDrD�RESSS
/ DISWASHER _...//rl Ile CI t L'NO
Data APPlrmm CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT If alter making this Certificate of ('j dc n
Exemption you should became subject to the Workers Compensation SWatMING POOL RECEPTOR
provisions of the Labor Code you must forthwith comply with such ADDRESS
provisions or this permit Mall be deemed revoked LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION WATER HEATER CRY TEL NO a
I hereby affirm that I em licensed under provisions of Chapter 9 STATE
(commencing with Section 7000)of Division 3 0l the Buslneae and CTAS SYSTEM 3 OUTLETS LICENSE NO
Professions Code and my license Is In full force and effect OF
r OUTLETS OVER DISTRICT NO BY
5 PER SYSTEM
License Number LK: Clam �DO 42�5.
Fl"LLVALIDA-4W-: W
contractor Date DATE (CITAL 428 _ 10
❑ I am exempt under sae FINAL 0� NEC k 4�E.10
B AP C for this reason CHANGE .011 I
Date Plan check fee ,
Signature TOTAL
PERMIT ISSUING FEES 1'jJQQ-0001 10/25/94
TOTAL FEE r❑ TO 3:10��9 1 AM
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor a License Law ' t'
for the following reason (Section 7031 b Busineu and Prolembns Address '
�
Code) city Tel No • t/I-' _ ` yar„ i_', r
I as,owner of the property will do the work end the structure
Is not Intended or offered for eels (Section 7014 Business '
and Profeaamns 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(Sac 3097 - -
CN C) i
Lender a Name
Lender a 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 mentioned
proper rinepecll rpoaes
SEE REVERSE FOR EXPLANATORY LANGUAGE
/o
SlgnabA of PermHtee DOM r
COUNTY OF LUS ANCELES 1EMPLE CITY it 0508 PLUMBIwf PERMIT
_ DEPARTMENT OF PUBLIC UORKS _ 5701 LAS TUNAS PL 0500 04082:0013
BUILDING AND SAFETY / LAND DEVELOPMENT I TEMPLE CITY CA 91780 '
- PHONE (626) 285-0488 ,EXT
LEGAL ID FEES PAID BUILDING 13fflfn�
ON FILE I 4923 SERENO DR J
FEE DESCRIDTION QUANTITY LON AMOUNT _ TEMP CA 917803035
ASSESSOR INFORMATION NUMBER _ NEAREST CROSS STREET EN_CINITA
5388-014-009 01 PERMIT ISSUANCE FEE • ' -' v 27 75 THOMAS PAGE 5% GnvO JS LOCALITY TEMPLE CITY
07 BATHTUBS/SHOWERS 3 00 FIX 48 60
TENANT 11 CLOTHESWASHER(S) 1 00 FIX 16 20 IS;UED ON PROCESSED BY PLIM BY EXPIRES ON
13 DISfIWASHER(S) 1 00 FIX 16.20 08/23/04 JK 02/19/05
21 HOSE BIBS(S) 4 00 FIX 64 80
WNERT 25 LAVATORIES/SINKS 8 UO FIX 129 60 FINAL DATE FINAL kY CODE
NOBLE, LESLIE 1 (909) 376-8816- 45 WATER CLDSET/URINAL S 00 FIX 81 00
4923 SERENO DR 51 IOW PRS GAS 5 OUTLET 1 00 SYS 16 20
TEMP 917803035 TOTAL FEES 400 35 UL5L;r
PL BING FOR THE ADDITION "
APPLICA4T 110
SAME AS OWNER
!,PECAAL
ACT APPROVALS S .�AW
SAME AS OWNER -
LIC NO UNDEN
WATER
PLASTIC Y/N METAL Y/N
RU Y PLUABING
'
LIC NO - GA�6T6 r17(i —I
v -
GAS VENT
hul
WIN
PLUYBING FIXTURES
LAWN SPRINKLERS
1b lt�i
UT�LITY COMPANY MOTIF M
Cw
GRAY 61ATER SYSTEM
REPORT ID DPR263 ROUTE TO BS0508 -