HomeMy Public PortalAbout4932 TEMPLE CITY BLVD_Plumbing__ WORKER BCOMPENSATION DECLARATION 7aome DPW aiee APPLICATION FOR PLUMBING PERMIT
.1 hereby alfum that I have a certificate of concent to cell Insure 7 0-OM
or a certificate of Worker a Compensation Insurance or a certified
copy thereof(Sec 3800 Lab C) ., .- _ _ _ • _
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS ;DEPT OF PUBLIC WORKS DIV I
Po No Company _ - .
CerUBed copy is hereby tumrehed
FOR APPLICANT TO FILL IN(PRINT OR TYPE) B"aDo F"SS lt�q 3 e1 TE M P L.E Q 11 Y t3 Lt/
❑ Certlllatl copy b Ned wo11 the county,MrlMlrrg Inspection _
deparunent NUMBER FIXTURE OR ITEM a FEE LOCAL"T .M r1`C (-- FTY I C-A Q 11 g b '
Data Applicant WATER CLOSET � lT
- CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB "Lzloss sr -,SPA R K L E ( T
COMPENSATION INSURANCEASSESSOR _
(rhIs section need not be oomplated If the work Involvetl by the SHOWER k1AP BOOK I PAGE PARCEL
permit Is for one hundred dollan($100)or less) , LAVATORY - a OWNER BTU 3�S O N LEON G
I cenity, that In the performance of the work for which this permit
is Issued 1 shell not employ any person In any manner ea as toSINK MAILRE93 s A.M E A S ���/�
become subject to the Workers Compensation Laws '
I 1 1 DISWASHER ' CITY - - TEL NO 2-97-Z 3
Dale Applicant CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT Iff after making this Certificate of
Exemption you should become subject to the Workers Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code you must forthwith comply with such ADDRESS '
provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION WATER HEATER TEL NO d
I hereby affirm that I am licensed under provisions of Chapter B
(commencing with Section 7000)of Division 3 of the Business and STATE UC
ProfeeMons Code and my license Is In full force and effect GAB SYSTEM OUTLETS LICENSE NO CLASS
OUTLETS OVER DISTRICT NO PROCESSED BV
` 5 PER SYSTEM �� Q
GGG[�vlL✓ H
License Number LIC Clew V
3FINAL
// VALIDATION WContractor pateLO ?� DOIBm exempt Under Sea _ z
C
B BP C for this reason
Plan check fee _`Y
Date PLUMBING PERMIT ISSUING FEE$ `_I3/ 3'X51
I0Signature TOTAL FEE �H 70 1 1T013
' l SINGLE FAMILY Plan check applicant i I ll t2t, 97 50
HOME OWNER BUILDER DECLARATION Name - 97.`1 l__
1 hereby affirm that I am exempt from the Contractor a License Law __ _ 1jj
for the following reason (Section 7031 5 Business and Professions Address CHANGE
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 7046 BusinessO�Z�
and Professions Code) ► ` c p.
�
�? Ji AM _�Ub
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of of the work for which this permit is Issued 18sc 3087,
Cm C)
Landw s Name _ r
Lender a Address
I certify Net I have read this application and state that the above 11011. '
Information Is correct I agree to comply with all County ordinances _
and State laws regulating Plumbing and hereby authorize
representathree of this County to enter upon the above-mentioned
property for inspection�Pyyrp'p�ee SEE REVERSE FOR EXPLANATORY LANGUAGE
Slgneture of Permittee Date 1 - '
COUNTY OF LOS ANGELES TEMPLE CITY 0 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC (ARKS i 9701 LAS TUNAS PL 0508 0201310011
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT
LEGAL ID FEES PAID BUILDING ADDRESS.
TR 14467 LT 16 4932 TEMPLE CITY SL
FEE DESCRIPTION QUANTITY: LEM. AMOUNT TEMP CA 917803868
ASSESSOR INFORMATION NUMBER NEAREST CROSS STREET SPARKLETT
8589-014-001 p' 01 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE. 597 GRID: A5 LOCALITY TEMPLE CITY
47 WATER HEATER(S) 1 00 UTH 16 20
TENANT 56 GAS REGULATOR 1.00 REG 16 20 ISSUED ON PROCESSED BY PLAN BY EXPIRES ON
TOTAL FEES 60.15 01/31/02 JK 07/30/02
OWNER. -TEF No: FINAL DATE -T�w BY CODE
VACA, DIANA AND CRUZ (626) 285-1319-
4932 TEMPLE CITY BL 3//v D7i
TEMP 917803868 = ur9nu6 um up WORK,
C/O WATER HEATER AND INSTALL GAS SHUT OFF VALVE
APPLICANT TEL NO
NICK TINKO (909) 392-8287-
4095 N FRUIT ST #809 -- - - SPECIAL CONDITIONS
-
LA VERNE
�NUELES C
� — -LTEL NO / \
NICKS REMODELING APPROVALS DATE lNgRTTU
(909) 392-8287- fi yd/�
4095 N FRUIT STREET LIC NO �7.� ./'�� \. UNDER SLAB WORK
SPACE 809 409663 B. / _ A
LA VERNE, CA 91750 - /� { t`5 `+ WATER SERVLL;t:
`�\ PLASTIC Y/N METAL Y/N
TEL ARCHITECT OR ENGi
LIC NO
GAS VENT
L(>;2 C C-�- 11`4 Viz'; � PLUMBING FIXTURES� HOT WATER HEATER
GAS TESTCWV
e
�-= MDR
146Ar&
- REPORT, ID: DPR263 ROUTE TO SS050B ~