HomeMy Public PortalAbout6009 TEMPLE CITY BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION 17GA067A v
hereby affirm that I have ir certificate of consent to self 'CB a,7(x-ao) APPLICATION FOR PLUMBING PERMIT �y
sure,or a certificate of Workers'Compensation Insurance,or �' u
certified copy thereof(Sec.3800,Lab.C.)
372256 ta't@ Com • Ins, Fund:' COUNTY OF LOS ANGELES BUILDING AND SAFETY
olicy No. Compan p
Certified copy is hereby furnished. % FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
r ADDRESS 6009 TeMple 'City ]31_Vd,
Certified copy is filed with the county'building Inspection NUMBER FIXTURE OR ITEM 0 FEE
e t t. John RieCl
WATER CLOSET LOCALITY Te le Cit
Date Applicant NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER George Taube
LAVATORY MAIL
(This section need not be completed if the work involved ADDRESS 603 Bartlett. CL
by the permit is for one hundred dollars ($100) or less.) SINK CITY San Gabar is, TEL.N028&3350 U
I certify that in the. performance of the work.for which this DISHWASHER CONTRACTOR i'
permit is issued, I shall not employ any person in any manner JO 13 Plumbs Service U
so as to become subject,to the Workers'Compensation Laws. ]. CLOTHES WASHER 4 CC
ADDRESS 9125 rji y Lab Tuna$ DY''.LVE
Date Applicant lL
SWIMMING POOL RECEPTOR d
NOTICE TO APPLICANT: If,after making this Certificate of CITY Temple City TEL.NO-285_3224 ow
-
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE [� LIC. z
Compensation provisions of the Labor Code,.you must forth ,� L'IC..ENSE NO:277687' CLASS 36 e
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked. .., l GAS SYSTEM OUTLETS 00 DISTRICT NO. k0reSSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER V L.
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7.000)of Division 3 of the Busi- FINAL
S�� VALIDATIO
ness and Professions Code,and my license is in full force andDATE.
effect.
a
279687 01-•36 BY AL `
License Number Lia Class
'Contractor John RiW t
Date��$1
I am exempt from the licensing requirements as I am a Plan Check fee
licensed architect or a registered professional engineer
50
acting in my professional capacity (Section 7051, Bus- PLUMBING.PERMIT ISSUING FEE$ 8
iness and Professions Code). TOTAL FEE 16 50
I
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that ;.am exempt from the Contractor's Address
License Law for the followin Section.7031.5, Busi- I
g reason ( ; City Tel.No.
ness and Professions Code): 021 5 6 A
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project _ # 0 0 00 05
(Section 7044,Business and Professions Code). I i
2 - 1650
'
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency o o d 1 5 0 C.)
for the performance of the work for which this permit is
-issued(Sec.3097,.Civ.C.).
Lender's Name 2027-81
Lender's Address i
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
autho ' repr ntatives is County to enter upon the
abov.-m ntio .. grope. mspecfion�purposes.
ure of Permi ee Date
76A667-CE817 3-59 _
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER h
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A.LAMRIE. County Engineer
CASSATT D. GRIFFIN.Sup t of Building LOCALITY o
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM OWNER - r
WATER CLOSET
BATH TUB ADDRdESS d i
CITY Pim.NO.
•
SHOWER
LAVATORY PoNTRA66R
SINS ADDRESS
DISHWASHER CITY TEL. NO e��/s
CO TRA R'S STATE
LAUNDRY TUB BE= TION NO. COUNTY
CLOTHES WASHER DISTRICTNO. GROUP Z NE P OCESSEDBY
WATER HEATER
GAS'SYSTEM INDUSTRIAL
WASTE APPROVAL
INSPECTION RECORD
G' OR FIXTURE $
APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT' $ 2�Oa'
UNDER SLAB WORK
TOTAL FEE ROUGH PLUMBING
GAS PIPING
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT
AND STATE THAT THE ABOVE 13 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. HOT WATER HEATER
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ' GAS TEST
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI ROP TY. UTILITY CO.NOTIFIED
SIGNATURE
OF PERMiTTE FINAL Z^9is'
i
®e VAMATIO ROBERT A.WOOD,
SUPERVISING MUCHMICAL•ENG?R
i
If;08 5 4 2 v; DEC 7 5 A 3.Q 0 ',