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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