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Home My Public Portal About5120 SERENO DR_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that 1 have a certificate of consent to self 76Aee7A insure or a certificate of Workers Compensation Insurance CE 817(REV 10/81) or a certified copy thereof (Sec 3800, Lab C ) COUNTY OF LOS ANGELES / , BUILDING AND SAFETY Policy No Company Certified copy is hereby furnished ❑ Certified copy is filed with the county building mspea- FOR APPLICANT TO FILL IN(PRINT OR TYPE) AUISS hon department NUMBER , FIXTURE OR ITEM ® FEE LOCALITY 'l Dote Appli9ant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB r CRO88 ST ,sJE'}"U COMPENSATION INSURANCE (This stolon need not be completed R the work Immlved by SHOWER OWNER -Oq,( C_,�s the permit Is for one hundred dollars($100)or less a LAVATORY ADDRESS O ,�20.¢�..�•�-j I certify thatd a the performance the work for which this SINK Z4 CITY T� '/�� TL TEL NO permit is issued, I shall not employ any person in any manner � so as to become subject to the Worker 'Compensation Laws , DISHWASHER (p �� CONTRACTOR 4rr�r G Date S-1 �7 ApplicantCLOTHES WASHER G' nn NOTICE TO APPLICANT If after making this Certificate of ADDRESSA C) -�_ < ys`7 Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM TEL NO 3 SO/72r/ with comply with such provisions or this permit shall be STATELIC deemed revoked WATER HEATER .i LICENSE No 35 7-c/G3 G TG LICENSED CONTRACTORS DECLARATION RICT NO By 1 hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER o and Professions Code and my license is in full force and affect 5 PER SYSTEM FINAL VALIDATION 6 License Number 3`J ZSFGS Uc Class G�G DAV—/J �¢ V FINAL ' � Contractor Dote BY �"N' Ell am exempt under Sec -7 77 6W N B 8P C for this reason Plan check feePooZ Date PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE 0 Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I O i,h A I hereby affirm that I am exempt from the Contractor's License Address Yr • • • • • 5Law for the following reason (Section 7031 5, Business and Professions Code) City Tel No 2 • • 7 Q 5 0 ❑ I, as owner of the property, will do the work and the structure a not d or offered for sale (Section PIP �•i• Q Jr-Oz v 7044, Business anndd ProfProfessions Code) ' � Q Q$�—(j 4 CONSTRUCTION LENDING AGENCY 1 hereby affirm that there n a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ C ) Lender s Nome Lender's Address I certify that I have read this application and state that the Poo information is correct I agree to comply with all County ordinances and Stole laws regulating Plumbing and hereby authorize representatives of this County to enter upon the above-litentioned pro y for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE iso gnature of Permittee Date T COUNTY OF LO-, ANGELS€ TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTM OF PUBLIC WORKS 9701 IAS TUNAS PL 0508 1105020007 BUILDING AND SAFETY / LAND DEVELOPMENT T LE CITY CA 91780 PHONE (626) 285-0488 EXT (LEGAL ID FEES PAID BUILDING ADDRESS ON FILE 5120 SERENO DR [FEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917803055 IASSESSOR INFORMATION NUMER I I NEAREST CROSS STREET 15388-011-013 101 PERMIT ISSUANCE FEE 27 80 THOMAS PAGE 596 GRID 145 LOCALITY TEMLE CITY Cl I 127 PRESS REG DEVICES) 1 00 DEV 16 30 1 1TEI'tANT 164 WATER PIPNG 1 1/2 1 00 LIN 16 30 11SSUED ON PROCESSED BY PIAN BY I TOTAL FEES 60 40 105/02/11 SR I I I I 1OWNER OLDF TEL NO FrrI_1�AL DATE( FIt CODE [OOLDFARH DANIEL HARRIET L (626) 357-1124- \ �O T 1 1518 BRADBURY RD IMROV 910163705 1 1 SMIPTION OF WORK 1 WATER MAIN AND ONE PRESSURE REGULATOR I [APPLICANT TEL NO [SALOME MODOCIO VARGAS (213) 392-1640- 4172 S NORMANDIE AV 1SPEC.Ar CONDITIONS 1 IAS ANGELES 90037 CONTRACTOR TEL NO 1APPROVALS DATE INSPECTOR SIGNATURE [ SAL T VARGAS PLUMING (323) 292-7683- [ 1 4172 NORMANDIE AVENUE LIC NO 1 [UNDE- SLAB WORX 1 1 LOS ANGELES CA 90037 772347 C36 WATER Sp/ (ICE PLASTIC[y/N METAL YIN ( ARCHITECT OR ENGINEER TEL NO - 1ROUGH PLUMING LIC NO [GAS PIPING I I [GAS VENT I I [HOT WATER HEATER I I I 1PLUMING FIXTURES (LAWN SPRINKLERS [GAS TEST I UTIL ITY COMPANY NOTIFIED I I Cwv GRAY WATER SYSTEM I I I I I I I I I I I I I I I I I I I I I ( I I I I I I I I REPORT ID DPR263 ROUTE TO BS0508 I I I I I I