HomeMy Public PortalAbout6234 SULTANA AVE_Plumbing__ WORKERS'COMPENSAT&ON DEOLARATI()N ?6A667A p ® /� A e
I hereby affirm that I have a' certificate of consep'r to seltr" ¢E elf(2-60) -rA 0—P L I C A T I®1 v FOR PLUMBING PERMIT
insure,or a certificate of Workers'Cotppensation Insurance,or„ II
a certified copy thereof(Sec.3800,Lab.C.)
COUNTY OF LOS ANGELES � / � BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING Si e /\ \ Q r ,� `f
ADDRESS (, J J lit '1-1 IBJ 1 ' D
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM O FEE
department. LOCALITY"r�' Lc= c Mr
(Date , Applicant WATER CLOSET
NEAREST I ,� /�^ + � �•y�
CERTIFICATE OF EXEMPTION FROM WORKERS' X BATH TUB CROSS ST.�V�17.1 G N ��5�1 tC �
COMPENSATION INSURANCE SHOWER OWNER PCoo
Q MAIL Gt
,(This section need not be completed if the work involved LAVATORY (T ADDRESS S Flo& 0
by the permit is for one hundred dollars ($100) or less.) SINK
CITY L TY TEL.NO
'I certify that in the performance of the work for,which this DISHWASHER !
permit is issued, I.shall not employ any person in any manner CONTRACTOR 0
so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER
ADDRESS U
Date Applicant SWIMMING POOL RECEPTOR d
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO. fn
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. Z
Compensation provisions of the Labor Code, you must forth- LICENSE NO. CLASS
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked. 1 GAS SYSTEM OUTLETS DISTRICT NO. PRO SSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL ./ VALIDATION
ness and Professions Code, and my license is in full force and DATE L� .L — S)?
effect.
FINAL
Acense Number Lic.Class BY
contractor Date
71 I am exempt from the licensing requirements as I am a Plan check fee 32-
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ ��
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
Ac.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's I'
Address
License Law for the following reason (Section.7031.5, Busi- I city Tel.No.
ness and Professions Code): I 2 2 9 0,0 A
71 I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project f! o 0 0 0 o 5
(Section 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY - 40.50
,
I hereby affirm that there is a construction lending agency 0 4 0 r. 0 x
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). i 0208-82
ender's Name
ender's Address
certify that I have read this application and state that the
bove information is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
rdinances and State laws regulating Plumbing, and hereby
uthorize representatives of this County to enter upon the
ove-mentioned property for inspection purposes.
Sign ure of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1210250020
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 5904 LT: 202 UN: .002 6234 SULTANA AV
]FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:] TEMP CA 917801553
ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: LONGDEN
15384-007-006 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 596 GRID: H2 LOCALITY: TEMPLE CITY, Cl
I 107 BATHTUBS/SHOWERS 1.00 FIX 16.20
ITENANT: 25 LAVATORIES/SINKS 1.00 FIX 16.20 JISSUED ON: PROCESSED BY: PLAN BY:
145 WATER CLOSET/URINAL 1.00 FIX 16.20 110/25/12 SR
I TOTAL FEES 76.40 ]
OWNER: TEL. NO: IFINAL D TE FI Y: CODE:
IVOONG, LE (818) 285-3863-
16234 SULTANA AV I I
ITSMP 917801553 IDESCRIPTION OF WORK
]REPLACE BATHTUB/SHOWER, LAVAROTIE AND WATER CLOSET FOR
BATHROOM REMODEL
APPLICANT: TEL. NO:
(SAME AS OWNER -
SPECIAL CONDITIONS:
I
I I
(CONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE
ISAME AS OWNER -
ILIC. NO I (UNDER SLAB WORK
IWATSR SERVICE
(PLASTIC Y/N METAL Y/N
(ARCHITECT OR ENGINEER: TEL. NO: ]
LIC. NO: I (ROUGH PLUMBING I A^
GAS PIPING I /-/Ly-'►-�� I -y
IGAS VENT
]HOT WATER HEATER I I I
IPLUMBING FIXTURES ]
I I (LAWN SPRINKLERS I I ]
IGAS TEST
UTILITY COMPANY NOTIFIED]
] IC I ] I
IGRAY WATER SYSTEM
I I i I I
(REPORT ID: DPR263 ROUTE TO: BS0508
] I I