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Home My Public Portal About5611 TEMPLE CITY BLVD_Plumbing__ WORKERS COMPENSATION (DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirmirm that ot I have o certificate of convent to self 7eP,667A insure, or a carhficate of Workers Compensation Insurance, CE 817(REV ID/81) or o certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company , Certified copy is kereby furnished BUILDING Certified copy is filed with the county building Inspe< FOR APPLICANT TO FILL IN(PRINT OR TYPE) AWRESS 1/ 1 051-aAr— yam.. 1 `, hon deportment NUMBER FIXTURE OR ITEM ® F �'s•/i,_� ,7 lita Date li ant WATER CLOSET Locelri 'Ew�E •TT ` P� �/7 APP S NEAREST f . CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST L►ve CSA' COMPENSATION INSURANCEE �r (This section need wiwo net be completed If the work Lh red by SHOWER ^ OWNER Q,Q6E /W /A/AJ /r• r',F the permH is for one hundred dollars($100)or Ins ) LAVATORYIL I certify that in the performance of the walk for which this ^ ADDRESS S6//��/1✓/D� C17r1 ,BLuD permit Is Issued, I shall not employ any person in any manner, CT1^�viwpi-e 6r�/ TEL NOa,aP6-403 so as to become subject to the Workers Compensation Laws DISHWASHER / CONTRACTOR Date Applicant CLOTHES WASHER C NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR ADDRESS AdM F-. Exemption you should become subject to the Workers Cis, TEL NO Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions m this permit shall be STATE LIC deemed revoked WATER HEATER LICENSE NO CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO 4SZD BY I here affirm that I am licensed under GAS SYSTEM OUTLETS ,� Q > by provnarts of Chapter 9 (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAd DATE VALIDATION v License Number L¢ Class � FINAL O / Contractor Date 1 By ID C I am exempt under Sec d N B BP C for this reason 2 Plan check fee Signature Dote PLUMBING PERMIT ISSUING FEE E rorALFEE �0595A Plan check applicant SINGLE FAMILY # • • • • • 5 HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Controctoi s License J� r( • e34.50 Law for the following reason (Section 7031 5 Business and Address s • • • 34 kProfessions Code) City Te506l No c321 -83 131 I as owner of the Property will do the work and the , structure is not Intended or offered for sale (Section 7044, Business and Professions Code) CONSTRUCTION LENDING AGENCY I 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 sAddress A t I have reed.ttrppbmhon and state that the ► maho 'co a late lep sen talion of IIs County to soler upon theti ed propms SEE REVERSE FOR EXPLANATORY LANGUAGE f PermlBee COUNTY OF LOS nuG4LCS TEm,11-F CITY ` H 0508 PLUMBINC f- ` DEPARTMENT OF PUBLIC WORKS 9101 IAS TUNAS PL 0509 Pw„� LJ39 BUILDING AND SAFETY / LAND DEVFIOPMENT Tli',.E CITY CA 91780 PHONE (626) 285-0488 LEGAL ID STf0 BUILDING ON FILE _ ',7611 TEMPLE CITY BE t - FEE DESfRIPfl'M QUANTITY U•)I AMOUNT TFMP CA 917802532 ASSESSOR INFORMAT,ON NUMBER NEAREST CROSS STREET °'CJ O:lAf 8588-007-014 01 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 597 GRlu ,3 LOCALITY TEMPLE CIT, _ 11 CLOTHESNASNER(S) 1 00 FIX - 16 20 TENANT-- 13 DISH64SHER(S) 1 00 F'X 16 20 T91FOff7d PROCESSED BY PLAN RY EXPIRES ON 21 HOSE BIBB(S) 1 00 FIX 16 20 10/06;04 JK 04/06/05 OWNER ILL NO 51 LW PPS GAS S OUTLET 1 00 S15 16 20 PENG LORI _ TOTAL FEES 92 55 TINA/y6F/� X/ FINAL BY 5611 TEMPLE C'TY BE TEMP 917802532 _ _ roT• PI(MRING FOR THE REMODEL W LAUNDRY APPLICANT CHEMP 013) 400-1841- 2626 BERKLEY AVE r�✓ ZONDITIONS LOS ANGELES CA 90026 C S CONTRvOTUR (;.i3) 413-1904- 2626 BERKELEY LIC NO MER SLAU W= LOS ANGELES CA 90026 386936 B R SERVICE P-ACTIC Y/N METAL Y/N SCHEN, JASON �__- `•�:-:'7_- ' - -- --- C/O 1139 !LENVIEII RD LIC NO W COVINA, CA 91790 Vk 1-AB-m-fi7TLSE§ — — 1-41.,ITSSPR It7KLR-? DTT �L APANY NOTTFTEf —— t,Ra7-Fi$T Ek SPSTEW REPORT ID DPR263 ROUTE TO BS0508 COUNTY OF LOS ANGELES TEMPLE CITY A 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL D508 0501310003 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE (626) 285-0488 EXT: LLUAL ID: FEES PAID --BIJILDING ON FILE 5611 TEMPLE CITY-BL ASSESSOR I FORMATION NUMBER: FEE DESCRIPTION' QUANTITY UION: AMOUNT - TEMP CA 917802532 - NEAREST CROSS STREET. BROADWAY 8588-007-014 01 PERMIT ISSUANCE FEE 27.75 THOUS PAGE 597 GRID. A3 LOTALITY: TEMPLE CITY 21 HOSE B1BB(S) 2.00 FIX 32.40 27 PRESS REG DEVICE(S) 2 00 DEV " 32.40 ISSUED ON: PROCESSED BY PLAN BY- EXPIRES ON 47 WATER HEATER(S) 1 00 WIN 16.20 01/31/05 JK 07/30/05 55 GAS METER (PRIVATE) " - 1 00 MET 16.20 - - TOTAL FEES 124 95 PENG LORI �' 5611 TEMPLE CITY BL TRIP 917802532OLSUKIPTION Ut WORKTr—c ADD 2 HOSE BIBRS 2 PRESSURE REGULATORS, 1 WATER HEATER APPLICANT: TEL NO- AND ONE GAS METER CHEMP (213) 400-1841- 2626 BERKLEY AVESPECIAL LOS ANGELES CA 90026 CONDITIONS:CONTRACTOR: lk:L NO' APPROVALS DATE INSPECTOMWOW— " C S CONTRACTOR (213) 413-1904- 2626 BERKELEY LIC NO UNDER SLAB WORK LOS ANGELES CA 90026 386936 B ARCHITECT OR ENGINEER -Tn--O: PLASTIC YIN METAL YIN CHEN JASON __ (626) 918-SM- C/O 1139 GLENVIEW RD LIC NO W COVINA, CA 91790 0040169 Wks PIPING _ GAS VENT HOT WATER HEAIFR LAWN SPRINKLERS GAS TEST UTILITY COMPANY NOTIFIED CWV GRAY WATER SYSTEM A REPORT ID DPR263 ROUTE TO: BSO508