HomeMy Public PortalAbout5953 TEMPLE CITY BLVD_Plumbing__ t;WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby,laffjrm that I'•have a certlficate of consent to self 78A887A
insure,or a certificate of Workers'Compensation Insurance, CE 817(REV.8/88)
or a certified copy thereof(Sec. 3800, lab. C.) LLLIII
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
P93olicy No. Company
Certified copy is hereby furnished. BUILDING �q �
❑ ADDRESS Certified copy is filed with the county building Inspec- FOR APPLICANT TO FILL IN(PRINT OR TYPE) 7 d-Gt CIP—) A4 V�
tion department. NUMBER FIXTURE OR ITEM ® FEE LOCALITY / ?'
WATER CLOSET '
Date Appligant NEAREST
// % y
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB G
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work Involved by SHOWER �N��
the permit is for one hundred dollars($100)or less.) LAVATORY MAIL
ADDRESS
I certify that In the performance of the work for which this !/�� CITY
permit is issued,I shall not employ any person in an SINK V TEL.NO.
manner N �j�
so as to become subject to the Workers' ws DISHWASHER
CONTRACTOR `L MM IAA
Date 'Z _3 ppli CLOTHES WASHER ADDRESSif
NOTICE TO APP (CANT:. If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL.NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE �� LIC. C,�
deemed revoked. WATER HEATER LICENSE NO. «/ CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS c /
(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 FINAL VALI T N C
License Numb ass ee— Aam/7 IL9,.l DATE Iz
C
C Date 12402 $ /✓ it F L �
L
❑ 1 m exempt under Sec.
B.BP.C. for this reason 2
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ I 61-0Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for.the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. ;27230A
❑ I, as owner of the property,,will do the work and the
structure is not intended .or offered for sale (Section , # G o o e o 5
7044, Business and Professions Code).
6 4 5 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for o o o b&5 0 c=i
the performance of the work for which this permit is Issued
(Sec. 3097, Civ. C.). 0 6, 1 1 ,P87
Lender's Name
Lender's Address
I certify that I have read this application and state that the ►
above information is coir �Iumlblng,
it'with all Count'
ordinances and aws and hereby
enter upon the
abo a erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
d
Signature of Permlitee • Dat
WARKERS*'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby,affirm that I have a'certificate of, consent,to self 76A887A ✓I I
insure, or a certificate of Workers'Compensation Insurance, CE 817(REV.8/88) lul
or a certified copy thereof(Sec. 3800, lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished. - �--gg //�� /^�y',/
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADD ESS J ��Fi�L C`/�� [ ��
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ 2 FEE LOCALITY , i
Date Appli4ant WATER CLOSET 3 O NEAREST Id
'
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. Ur7O
COMPENSATION INSURANCE OWNER AeW
(This soction need not be completed if the work Involved by SHOWER MAIL
�j. `�� N�■
the pormit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK CITY �� TEL. NO.?/
so as to become subject to the Workers' ens ws• DISHWASHER
CONTRACTOR
Date U ppliea CLOTHES WASHER ADDRESS /"
Date TO PP (CANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY $
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM TEL. NO.
S� TEL.
with comply with such provisions or this permit shall be STATE c�G+ LIC.
deemed revoked. WATER HEATER 6194 &2ArC- 1 LICENSE NO. y O CLASS
LICENSED CONTRACTORS DECLARATION / DISTRICT NO PROC D B
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM r OUTLETS 0 S
(commencing wi}h Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and y license is in full force and effect. 5 PER SYSTEM FINADATE VALIDATIV N
License Numb Lic.Class d
off(' gY h
Cont t Date C
❑ I am exempt under Sec. O
0?
B.&P.C. for this reason Plan check fee , 2
Signature
Date: PLUMBING PERMIT ISSUING FEE$ /� J
TOTAL FEE �j V 5- 07221 A
Plan check applicant
SINGLE FAMILY # 0 0 0 0 0 5
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address I o 1 3 Q 5 0
Law for-the following reason (Section 7031.5, Business and 0 0 1 3 Q 5 0
Professions Code): City Tel. No.
❑ 50
I, as owner of the property,.will do the work and the ® 0 6 1 0 87
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'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 01111.
ordinances and State laws regulating Plumbing, and hereby
authorize repreNWkIelves of this County to enter upon the
above-%ed propert ion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
`� ignature of Permittee Date
� r ,
CGUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS PL 0508 9712300003
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
GAL ID: FEES PAID BUILDING ADD S :
ON FILE 5953 TEMPLE CITY BL
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 91780
ASSESSOR OR ION UM8 . NEAREST CROSS STREET: WOODRUFF
01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY, C
25 LAVATORIES/SINKS 1.00 FIX 16.35
TENANT: TOTAL FEES 44.10 ISSUED ON: PROCESSED B LA BY: EXPIRES ON:
12/31/97 VG 12/31/98
OWNER: TEL. NO: FINAL DATE �nTY: CODE:
CHANG, BOB C (818) 289-4088CAr
-
238 S. ATLANTIC BLVD
ALHAMBRA, CA 91801 DESCRIPTION OF WORK
INSTALL 1 HAND SINK
APPLICANT: TEL. O:
EVERSTRONG CONSTRUCTION, INC (800) 933-8913-
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
EVERSTRONG CONSTRUCTION, INC. (800) 933-8913-
1033 WESTMINSTER AVE. LIC. NO UNDER SLAB WORK
ALHAMBRA, CA 91803 721681
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: TEL. NO:
ROUGH UMBI G
LIC. N0:
' GAS PIPING
GAS VENT
0 WATERTR
PLUMBING RES
LAWN SPRINKLERS
GAS TEST
UTILITY CO PA 0 FIE
CWV
GRAY WATER SYSTEM
REPORT ID: DPR263 ROUTE TO: SS0508