HomeMy Public PortalAbout5403 TEMPLE CITY BLVD_Plumbing__ WORKERS COMPENSATION DECLARATION
I
her"1:1y .affirm that I have a certtficote of consent to self in , ;A PW 4/87 APPLICATION FOR PLUMBING PERMIT
sure,or a cenificote of Workers Compensation Insurance or a CE 817(REV 8/86)
certified copy thereof (Sec aLob C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No —Company ,
Certified copy is hereby furnished
clor
Certified co n hied with the coup building in FOR APPLICANT TO FILL IN(PRINT OR TYPE) - BUILDING ZJ C/
PY county g spection ADDRESS p
department } NUMBER FIXTURE OR ITEM @ FEE �,LN/� LOCALITY
Dole Applicant 2 WATER CLOSET(TOILET) W NEAREST L
CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BATH TUB Q CROSS ST
COMPENSATION INSURANCE SHOWEROWNER, o i GHI/f'Q
(This section need not be completed if the work Involved by MAILO� - ArS -
the perinft Is for one hundred dollen($100)or less) LAVATORY ADDRESS a I_ ~ i
I certify that in the performance of the work for which this per- SINK �y}�
ma is issued I shall not employ any person in any manner so _CITY Eta L'( TEL tJ0 27 '
as to become subject to theWorkCompensation Laws DISHWASHER
TZ
'17 CONTRACTOR
Date y� Applicant F,!qM K (,441PCLOTHES WASHER ADDRESS
APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR -
Ex-
emption you should become subject to the Workers Compen CITY
EL NO
sahon provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- _ STATE UC
ed J. WATER HEATER LICENSE NO
CLASS
- LICENSED CONTRACTORS DECLARATION DISTRICT NO SSED Y
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �•i(!�
9(commencing with Section 70DO)of Division 3 of the Business OUTLETS OVER .JIV/�
and Professions Code and my license is in full force and ef- 5 PER SYSTEM FINAL (( ) V (DATION
fect DATE (�
License Number Lic Class U
FINAL Im
Contractor Dote BY O
I am exempt under Sec yt
8 BP C for this reason Plan check fee R 9 6 9,4 A vdi
I,
Dote PLUMBING PERMIT ISSUING FEES # 5
Signature _ TOTAL FEE 1 • s 7 6 5 Q
SINGLE FAMILY r
HOME OWNER-BUILDER DECLARATION Plan check applicant s s s 7 6 5 0 5
I hereby affirm that I am exempt from the Contractor s License Nome
Law for the following reason (Section 7031 5 Business and ' Q 5 2 5—8 8
Professions Code) Address
I, as owner of the property will do the work and the City Tel No
structure is not intended or offered for sale(Section 7044
Business and Professions Code) I ► '
CONSTRUCTION LENDING AGENCY -
I hereby offirm?hot there is o construction lending agency for t the performance of the work for which this permit is issued
(Sec 3097, Cw C ) '
Lenders Name
Lender s Address
I certify that I hove read this application and state that the - -
above information is correct I agree to comply with all County ► -
ordinances and State lawn regulating Plumbing, and hereby
authorize representatives of this County to enter upon the '
a e mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date i +
I '
COUNTY OF LOS ANGELES THM➢LE CITY 4 0500 PLUKEING PERMIT
DSPARTKERTSAF OF PUBLIC DEVE 9701 LAS TUNASPLPL 0508 0605760015
_
BUILDING AND SAFETY / LAND DHV�,O➢M89T PHONE CITY G 91740
PHONE (676) 785-0484
LEGAL ID PEES PAID BUILDING ADDRESS
TR 11789 LT 5 5403 TEMPLE CITY HL
PHB DEBCEIPTIOd pID1YlIT'Y 0011 AMOUNT t TEND G 917903151
ASSESSOR INFORMATION NUMBER NEAREST CROSS STREET OLIVR -
8588-075-005 01 PERMIT ISSUANCE FEE 77 75 i MON" PAGE- 597 GRID A4 _LOCALITY T@IPLB CITY C
47 MATER NEATER(S) 1 00 NTH 16 70
TsmA TOTAL FEES 43 95 ISSUED ON PROCESSED BY PLAN BY 'EMPIRES ON
05/76/06 JX 11/77/06
CHIAO PAO H,LINDA B (676)OWNER 1,785-1187- FINAL GTE EXPIRY CODE
5403 THMPLB CITY BL 1
TEN? 917803151 , - DESCRIPTION-UF-AHK
NATEP HEATER CHANGE OUT
A➢PLICANT TEL NO '
T66ANA (310) 515-1311-
17111 B BROADWAY SPECIAL CONDITIONS
GARDENA G 90748 _
CONTRACTOR TEL NO APPROVALS DATE INSPECTOR SIGNATURE
ACTION CONTRACTORS (310) 515-1311- `
17111 SOUTH BROADWAY LIC NO _ UNDER BLAB KORA '
GARDENA G 90248 5/1,00000 • -
MATER SERVICE
PLAB'_"IC Y/N METAL YIN
ARCHITECT OR ENGINEER TEL NO
ROUGE PLUMBING
LIC NO
GAS PIPING
GAS TEST
(
HOT HATER HEATER
PLUM9Id0 HIxTVRHB
t
LAWN�SPRINA1,RRB -
GAS TEST
UTILITY COMPANY NOTIFIED '
CMV
,
GRAY,NATER SYSTEM
• ADDITIONAL DATA ON PILE
I
REPORT ID DDR763 ROUTE TO 080508