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Home My Public Portal About5526 TEMPLE CITY BLVD_Plumbing__ TeAeeT.cemT 4-e4 APPLICATION FOR PLUMBING PERMIT COUNTY OF LOS ANGELES D B[A�R]�pT�GNTry�UO�}FyQCr��O��Ual.NaPTayY NGINMBUILDING JOTiN A LAMtlIt oG UNTY �NOIM!!R DHF$a o v WILLIAM A JENSEN SUP T OF BUILDING FOR APPLICANT TO FELL IN CROSS el T NUMBER FIXTURE OR ITEM EACH FE[ OWNER WATER CLOSET $125 -� MAIL LATH TITS 1 y5 � ADDRESS GTT O SHOWER 1 R5 y LAVATORY 1O CONTRACTOR SEN[ IIS ADDRESS J.70 —3 D�IWASFM 175 Gn TEL NO A >S7 LAUNDRY TDR 1 I5 REGISTRATION eATor NO^ COUNTYTTATE CLOTHES WASHES 115 DISTRICT NO GROUP ION! HSSHD BY WATER HEATER 1 SS l_ Y OAS SYSTEM 1:3OD71J:T8 1 WASTE APPROVAL O OUTLETS OVER 5 PER SYSTEM .ID INSPECTION RECORD U GC 0 6� v 1 APPROVALS PATEIMsrsCTo436SIGN _ MMS, RMIT j 2 00 UNDER SLAB WORK ROUGH PLUMBING TAL FEE GAS PIPING n /1 1 HEARST ACKNOWL1 MAK RUO THIS ATLIG ON GAS VENANO STAT[ THAT TH[ CORRECT AHO AORM TO COMPLfWITH ALL COUNTY AND "A" LAW[ ANGULATING HOT WAVER NEATERPLUMBINGI M[RKSY C[RTIIY PROPERLY R[OIR[R[D AND/OR PLUMBING FIXTURELIC[N\[D AS R[OUIR[ ANGELES CO NTY AMD RATE OF T,AS TE6TGLIIORMIA OR THAT L[WL OW R OP AMD INTpD TOREnGaIMTN[AYOv[ RESIDE A ROP[RTY UTILITY C NOTiFiEbSIGNATURE �` C/ OF PERMITTE � FINAL /V$LIDATION ROBERT A WOOD <N M o cweN SUPERVISING MECHANICAL ENG R � � 05o00 a'n13 5 D 35.75- 11 76AS67 -CM4617 11-04 C. //, ^^ / APPLICATION FOR�f�PLUM'IBIN/G �E MIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGHADDRESS BUIIBXGLIND SAFETY FIVISDING JO MBIE COUNTY NOINEMSS COLEMAN W JENKINS SUPT OF BUILALITY FOR APPLICANT TO FILL IN h NUMBER FIXTURE OR ITEM EACH ER WATER CLOSET 9195RATE TDB 195 SHOWER 125 CITY TEL No LAVATORY 195 CONTRACTOR SINE 195 ADDRESS D/SHWABHEH 193 CITY NO LAUNDRY IVU 193 9Ea16TRATTON COUNTY CLOTHES WASHER 195 DIRT R a OUP ON! SBFD BY WATER HEATER ISO G' GAS SYSTEM OUTLETS 150 INDUSTAIAL 'Y WASTE APPROVAL 6 OUTLETS OVER 5 PER SYSTEM 30 INS ECT10N BD C3 F / BE D - 19 -- v O H W CL N Y APPROVALS DATE INSPECTOR SSIGNATURE PERMIT j p 00 UNDER SLAB WORK ROUGH PLUMBING TOTAL FEE GAS PIPING 1 HERESY ACKNOWLKO" THAT 1 MAY[ BRAD T1411 APPLICATIO GAS VENT AMO STAT[ THAT TM[ ASOY{ It CORRECT AND AOR[{ TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAW[ REGULATING HOT WATER HEATER PLUMBING I H[II[SY CERTIFY THAT I AM PROPERLY R[ RED AND/OR PLUMBING FIXTURES LICCHt{O AS R[pUIREO SY • AMO{L{t COU ANO CTAT[ OF CALIRMNIA OR THAT 1 A { L[ WM[ F D IMT[RD TO GA$TENT "SIM IN THE ABOVE CRIS[o TIA R UTILI O NOTIFIED SIGNATURE IL OF PERMITTE pINAL VALIDATIOIf----)ROBERT A WOOD CK M o CASH /SUPERVISING MECHANICAL ENG R LjQ 4 6 1 *3-, AUG 13 5 D 3.50- I. .50-1 WORKERS'COMPENSATION DECLARATION taAaarA I hereby affirm that I have a certificate of consent to ,cif caao (x-se) APPLICATION FOR PLUMBING PERMIT insure or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C) 1P81139�Q Fremont Indemnity COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy mpany l t Certified copy n hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) ' BUILDING Certified copy n flied with the county budding inspection NUMBER FIXTURE OR ITEM • FEE ADDRESS 5526 Temple Ctt Y Blvd, department LOCALITY Data Applicant Bryant HCg. WATER CLOSET Fl_eRE—A BATH TUB CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE SHOWER OWNER Tom Schaub (Tho section need not be completed if the work Involved LAVATORY MAIL by the permit is for one hundred dollars ($100) or less) ADDRESS - SINK CITU Temple City TEL No2g6-348 a I certify that in the performance of the work for which this DISHWASHER permit n issued, 1 shall not employ any person In any manner CONTRACTOR Br x so as to become subject to the Workers' Compensation Laws CLOTHES WASHER O ADDRESS lU— Date Applicant SWIMMING POOL RECEPTOR NOTICE TO APPLICANT If, after making,thu, Certificate of DITySan Gabriel TEL N0286-1141 a Exemption, you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE LIC Cn Compensation provisions of the Labor Code you must forth WATER HEATER LICENSE NO 221751 CL Z with comply with such provisions or this permit shall be deemed revoked 1 GAS SYSTEM OUTLETS3 00 DISTRICT NO PKOCESSED BY oQ LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter S PER SYSTEM 9 (commencing with Section 7000)of Division 3 of the Busi FINAL ID T nae and Professions Code and my license n in full for" and DATE ��Z-�a'� effect Lie Class License Number 2217 51 C20 FINAL - - FI Contractor Bryant Htg. Date I am exempt from the licensing requirements as 1 am a Plan Check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ 7 0 acting in my professional capacity (Section 7051, But iness and Professions Code) I TOTAL FEE 10100 Lie or Reg No Date LNa check applicant HOMEOWNER BUILDER DECLARATION e 1 hereby affum•that I em exempt from the Contractor'sress 81 593A License Law for the following reason (Section 7031 5, Busi Tel No # •,• • • • 5 ness and Professions Code) 1, as owner of the property, am exclusively contracting 2 • • 1 Q 0 0 with licensed contractor to construct the project (Section 7044, Business and Professions Code) • • • 1 0 0 0 6 CONSTRUCTION LENDING AGENCY 1 019-81 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec 3097,Civ C) Lender's Name Lender's Address I certify that 1 have read this application and state that the above information n correct I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE ordinaprfs and State lam regulating Plumbing, and hereby oithq,zJ representatives of thi unty to enter upon the a)0v ntioned property r coon par s io gel Signature of Permittee Data WORKm that I have a ION DECLARATION rawaa>w APPLICATION FOR PLUMBING PERMIT 1 hereby affirm that I have + certificate of consent to self CK. (., insure, or a certificate of Workers'Compensation Insurance,or ^ 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 ADDRESS ` 1GL ^C� L Certified copy s filed with the county budding inspection NUMBER FIXTURE OR ITEM • _FEE department WATER CLOSET LOCALIT iN +�L �- Date Applicant NEAREST NN' - BATH TUB CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNERMAIL (This section neednot be completed If the work myOlYed LAVATORY ADDRESCL by the permit s for one hundred doWrs ($100) or leu) I SINK CITY �/y G/�il�� TEL NO Jp6pagP I certify that in the performance of the work for which thta DISHWASHER CONTRACTOR permit a issued, I shall not employ any person any manner O so as to become subject to t nsatwn La CLOTHES WASHER ADDRESS U Date Applican SWIMMING POOL RECEPTOR W NOTICE TO APPLICANT If after making this Certi cate of CITY TEL NO y Exemption you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC Compensation provisions of the Labor Code, you must forth LICENSE NO CLASS with comply with such provisions or this permit shall be WATER HEATER deemed revoked GAS SYSTEM OUTLETS DISTRICT NO PROCESSED BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER S• vC� I hereby affirm that I am licensed under provisions of Chapter S PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Bus, FINAL nes and ProfessVALIDATION ions Code, and my license s in full force and DATE - '�' effect FINAL Qi- License Numbec Lie ClassBY - Contractor Date I em exempt from the licensing requirements as I am a Plan cheek fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ OO acting in my professional capacity (Section 7051, Bus loess and Professions Code) ITOTAL FEE pi Lie or Reg No Date Plan check applicant HOME OWNER-BUILDER DECLARATION [dilreirs ame I hereby affirm that I am exempt from the Contractors 6 Q 5 A License Law for the following reason (Section 7031 5, Busi ity Tel No ness and Professions Code) - # a a a a a 5 I, as owner of the property, am exclusively contracting • • 9.00 with licensed contractors to construct the project (Section 7044, Business and Professions Code) • a a1 Q Q Q Tu CONSTRUCTION LENDING AGENCY - - I hereby affirm that there is a construction lending agency I Q 2 6 -8,1 for the performance of the work for which this permit a issued (Sec 3097,Civ C) Lender's Name Lenders Address I certify that I have read this application and state that the above information s correct I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE ` ordinances and State laws regulating Plumbing, and hereby authorize representative of this County to enter upon the ve-m n for inspe ion purposes �p s Signature of Permittee Date