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Home My Public Portal About5208 TEMPLE CITY BLVD_Plumbing__ I- - - 'WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING. PERMIT I hereby affirm that I have a certificate of consent to self in 76 x667 DPW 4/87 /'�I sure ar a certificate of Workers Compensation Insurance or E 81 7( ylLJll Pe CE 817(REV B/eb) certified copy thereof (Sec 3800 Lab C ) a Policy No Company COUNTY OF LOS ANGELES' DEPT OF PUBLIC WORKS 7 Certified copy is hereby furnished BUILDING ❑ Certified copy FOR APPLICANT TO FILL IN(PRINT OR TYPE)n TJed with the county budding inspection department NUMBER FIXTURE OR ITEM @ FEE LOCALITY Data Applicant WATER CLOSET(TOILE?) NEAREST,J CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CR055 SY ' COMPENSATION INSURANCE - SEIOWER s OWNER (This section need not be completed If the work Involved by - MAIL the Permit Is for a"hundred dollars($100)or Iess ) LAVATORY MAILADDRESS I certify that in the performance of the work for which this per- SINK CITY TEL NO mit is issued I shall not employ any pen many mannarao ' as to become subject to the Workers lotion La bISHWASHER > CONTRACTOR Dot./—d-// Appbcant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT If after ng this Certificate o Ex- SWIMMING POOL RECEPTOR emotion you should become su t to the Workers Com CITY TEL tJ0 lotion provisions of the Labor C e you must forthwith comp LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC ed WATER HEATER Q LICENSE NO CLASS LICENSED CONTRACTORS DECLARATION I DISTRICT NO ROCFSSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER ;Q and Professions Cade and my license is in full force and of 5 PER SYSTEM 4FINALfact VALIDATION ATE 60 License Number tic Class FINAL U 0 Contractor Date BY O O lam exempt under Sac B 8P C for this reason Plan check fee Dote PLUMBING PERMIT ISSUING FEE$Signature TOTAL FEE ;9 O 8 a O A SINGLE FAMILY Al l e s s e 5 HOME OWNER-BUILDER DECLARATION Plan check applicant - ( �j S O I hereby affirm that I am exempt from The Contractor's License Name e e e16506 i Low for the following reason (Section 7031 5 Business and Profs ions Code) Address I Q 10—8 8 NZ I as owner of the property will do the work and the City Tel No structure is not intended or offered for sole(Section 7044 Business and Professions Code) ► CONSTRUCTION LENDING AGENCY I hereby off irm that there is a construction lending agency for r the performance of the work for which this permit is issued i (Sec 3097, Civ C ) Lender s Nome 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 reWasonlotvas of Ihis C unty to enter upon the - abov ant ned ro ons tion purposes ^ SEE REVERSE FOR EXPLANATORY LANGUAGE Sr ule of Permihee Date - WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT he'rgby affirm that I have a cenifcate of lonsent to self in 720-=6 667APw 4/87 sure,ora certificate of Workers Compensation Insurance or a CE 817(REV 8/86) , certified copy thereof (Sec 3800 Lab C ) Policy No ' Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS Certified copy is hereby furnished ' FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING �1 t Certified copy a filed with the county building Inspection ADDRESS (/ e e, department NUMBER FIXTURE OR ITEM e FEE LOCALITY Date.Applicant WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS COMPENSATION INSURANCE SHOWER OWNER ✓Q -BC / L t (This section need not be completed N the'work Involved by MAIL ! // the permit Is for oM hundred dollars ($100)or lass) LAVATORY ADDRESS J�� 7s,' L / ✓ I certify that in the performance of the work for which this per T/11 mit is Issued, I shall not employ any person in any manner so SINK CITU L/ TEL NO Is V_J as to become subject to the Workers Compensation Laws _DISHWASHER IF CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS i — NOTICE TO APPLICANT If after making this Certificate of Ex SWIMMING POOL RECEPTOR emption you should become subject to the Workers,Compen CITY TEL NO sation provisions of the Labor Code you must forthwith comp LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE tic ed i I WATER HEATER LICENSE NO CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY I hereby off lrm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS Q r D /y 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER / and Professions Code and my license is In full force and of 5 PER SYSTEM FINAL3/ VALIDATION fact DATE 0. License Number Lc Class U FIN IL Contractor Date BY p H ❑ I am exempt under Sec W a B 8P C for this reason z • Plan check fee , z -Date PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Q SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant � 1 hereby affirm that I am exempt from the Contractor s License Nome Law for the following reason (Section 7031 5 Business and AL'.� eyr Professions Code) Address - 0;;�l ll.70 1, as owner of the property, will do the work and the City Tel No 1 .I.�,,` structure a 44 not Intended or offered for sale(Section 70 Busmess and Professions Code) , TfITKL 20 . 50 CONSTRUCTION LENDING AGENCY CHEJ.1L 213.7_ sl hereby off irm that there is a construction lending agency for the performance of the work for which this permit is issued LHAW]E ,fJa (Sec 3097, Civ C ) Lenders Name 1lQQQ—I]fjl]], '/1i•'+1 Lender's Address 568,t 1 Am 9:0_, 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 ' s` authorize ppresentotives of this County to enter upon the a m honed pro for a tion purposes °` SEE REVERSE FOR EXPLANATORY LANGUAGE igrwture of arm tee Date t COUNTY OF LOS ANGELES TEMPLE CITY it 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0308050001 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE (626) 285-0488 EXT LEGAL ID: FEES PAID BUILDING ADDRESS TR 15683 LT 103 5208 TEMPLE CITY SL FEE DESCRIPTION QUANTITY LXNI AMOUNT TEMP CA 917803832 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET LA ROSA 8589-013-025 01 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 597 GRID A4 LOCALITY TEMPLE CITY 07 BATHTUBS/SHOWERS 2.00 FIX 32 40 TENANT 25 LAVATORIES/SINKS 2 00 FIX 32 40 ISSUED ON PROCESSED BY: PLAN BY EXPIRES ON 45 WATER CLOSET/URINAL 2 00 FIX 32 40 08/05/03 JK 02/01/04 47 WATER HEATER(S) 1 00 WTH 16 20 FINAL BY CODE SIMANGINSONG, LUSER 6 MARIA (626) 309_1127_ 51 LOW PRS GAS 5 OUTLET TOTAL FEES SYS 157 35 5208 TEMPLE CITY BL �� 716 20 FINAL / TEMP 917803872 F WURK PLUMBING FOR 2 NEW BATHROOMS 8 RELOCATION OF HVAC APPLICANT TEL NO SAME AS OWNER SPECIAL CONDITIONS CONTRACTOR APPROVALS DATE INSPECTOR SIGUTUWF-- SAME AS OWNER LIC NO H h \ NUNDER SLAB WORK \\ WATER SERVIC� ARCHITECT OR ENGINEER TEL NU �� \\ \ PLASTIC Y/N METAL Y/N �,� -1 ROUUH PLUMBING LIC NO:� ! ___ \1\ Y- ��G!!� CWV REPORT ID DPR263 ROUTE TO BS0508