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HomeMy Public PortalAbout6023 TEMPLE CITY BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT ' d..i here. e4ffirm that I have.a certificate of consent to self. 76A667A . '_r-+ -A6 re ?or a certificate of Workers'Compensation Insurance, ,CE 817(REV.. 10%81.) _ or a certified copy thereof(Sec. 3800;Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company , Certified copy is hereby furnished. BUILDING y AA �jl FOR.APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS ©L — f �t �/!✓. Certified copy-is filed with the county building inspec- NUMBER FIXTURE OR ITEM tion:department. @ FEE LOCALITY P� WATER CLOSET Date Appl iga nt NEAREST CROSSST.TUB T. / �� rX CERTIFICATE OF EXEMPTION FROM WORKERS' BATH , r,• COMPENSATION.INSURANCE OWNER (This section need not be completed'if the work involved by SHOWER. ��( the.permit Is for one.hundred dollars($100)or les ) IAVATORY ADDRESS r ( � I MAIL I certify that. in the performance of the work for hick This If permit is issued', I shall riot employ any person n a manner SINK. CITY ^ t TEL.NO. so as to become subj ct to the War en tion Laws. t P DISHWASHER r CONTRACTOR /w / , , , fir Date Applicant' J CLOTHES WASHER ADDRESS Q NOTICE TO APPLICANT: It of r m� cing this Certificate of ► �J Exemption, ,you should bec a subject to the Workers' SWIMMING POOL RECEPTOR / Compensation provisions.of the Labor Code, you must forth- CITY 01 r TEL.NO. 0 with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE Z LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED.CONTRACTORS DECLARATION 'DISTRICT NQ._ P OCE55Eb BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM 27OUTLETS. (/JJy (commencing with Section 7000 of Division 3 of the Business l ( 9 ) OUTLETS OVER � and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALID ION O DATE License-Number Lic. Class 96 FINAL O Contractor Date BY erd ❑ a I am exempt under Sec: ` � ' B.&P.C. for this reason ism R1 01.9A Plan check fee V Dare; f... ► #'o'0 0 0 0 5 PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE ) b o a 4,5:0 SINGLE FAM Plan check applicant .I.LY - HOME OWNER-BUILDER DECLARATION Name' o ­ 31L505 I hereby affirm that I am exempt from the Contractor's License ( 1.07-84 Law for the following reason (Sectidn 7031.5, Business and Address Professions Code): City Tel.No. ❑ 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's Address I certify that I have read this application and state that the , above information is cor ct. I agree to comply with all County A.ordinance.and S to s regulating Plumbing, and hereby epres nt es of this County to enter upon the T' n perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE f Permittee `Date® WORKERS'COMPENSATION DECLARATION rsassiw ,,.I hereby; affirm that I have ir certificate. of.consent to self cu a»lz-eo). APPLICATION FOR PLUMBING PERMIT insure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,1 Lab.C.) ' 'fl COUNTY OF LOS A.NGE ES 1' BUILDING.AND SAFETY Policy No. . .Company O Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ` L ADDRESS I department copy filed with the.county building inspection NUMBER FIXTURE OR ITEM FEE LOCALITY "M . WATER CLOSET Date—Applicant NEAREST * d. BATH TUB CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' + N� COMPENSATION INSURANCE SHOWER. OWNER .� MAIL. (This section need not be completed if the work involvedLAVATORY.. � ADDRESS, by the permit is for one hundred dollas ($100) or less,). SINKO ' CITY TEL.NO. U I certify that in the performance of the work for which this DISHINASMEFi permit_is issued, I shall not.employ'any;person in.any manner - Q O ' C ONTRACTO'R so asto-become subject..to the Workers'Compensation Laws. CLOTHES WASHER i4DDRESS Date Applicknt SWIMMING-POOL RECEPTOR ill NOTICE TO APPLICANT:If,,after making this.Certificate of CITY TEL,,NO.: a- Exemption, you should become subject to the Workers' LAWN SPRINKLERSYSTEM LI STATE. LI.C. Compensation provisions of the•Labor Code, you must forth- LICENSE'NO. CLA. with comply with such provisions or this permit shall be WATER HEATER deemed.revoked.: GAS SYSTEM OUTLETS, CT NO. .. DIS 'IrR` � •CESSED 'lf LICENSED CONTRAC.TO'RS.DECLARA 1 N OUTLETS OVER c I Hereby affirm that I am licensed under•Provisions of Chapter 5 PER.SYSTEM 9 (commencing with Section 7.0.00)of Division 3 of the Busi- FINAL VALIDATION ness and Professions Code,.and,my license is in.full force and DATE. - ' effect. License Number .' Lid,Class. - — BY L FI.NA . Contractor Date F1 I am exempt from the.licensing requirements as I am a Plan.check fee licensed architect. or a'registered professional engineer acting in my professional capacity,,(Section 7051,. Bus- PLUMBING PERMIT ISSUING.FEE$' iness and Professions:.Code.). TOTAL FEE Lac.or Reg.No. 'Date. Plan check applicant -- HOMEOWNER-BUILDER DECLARATION Name :I hereby affirm that I am exempt. from the Contractor's Address. License. Law for the following,reason (Section.,.7031.5, Busir City Tel.No. Hess and Professions Code): •, ,❑ I, as.owner of the property,:am exclusively contracting with licensed contractors to construct the project (Section 7044,Business and Professions Code). 2 011 1.3 A• C.ONS.TRUCTION.LENDING AGENCY # o o. 0 0 o rj I hereby affirm that there is a•construction lending agency for the performance of tt4e work for which tfi.L permit is 2.0 :-. 1'4.00 issued(Sec.3097,Civ.C.). . , Lender's Name 0 0 0 �: 6 0 0,X Lender's Address' i6 2'9_8'1. ^ I certify that I have'•rea..d this application and state that the above information is correct:I agree to comply with all County ordinances and State laws regulating: Plumbing, and hereby SEE REVERSE FOR EXPLANATOIRY LANGUAGE 'authorize representative§ of this County to enter upon the a ve-m tion..ed property tQr ipspe on;gurposes. Signature of Permit a Date ; Asn /%> 5/70 E APPLICATION. FOR PLUMBING PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY EN FEER BUILDS AND SAFETY DIVISION aaDREss a JOHN A.LAMBIE..COUNTY ENGINEER COLEMAN W:JONKINS. SUPT. OF BUILDING LOCALITY ' FOR.APPLICANT TO FILL IN PR NT OR TYPE NEAREST CROSS ST.. !✓ P /�/C NUMBER FIXTURE OR-ITEM EACH' FE6 OWNER WATER CLOSET 1.5'0 NAIL , HATH TUB 1.50 ADDRESS SHOWER 1.50 CITY TzLfNOv296 LAVATORY 1.50 CONTRACTO SINK 1.50 ADORES$ DISHWASHER 1.50 CITY TEL-'NOA : - CLOTHES WASHER 1.50 STATE LIC LICENSE,NO. Q CLASS SWIMMING POOL RECEPTOR 1.50 DISTRICT NO. GROUP ZONE PROCESSED BY LAWN SPRINKLER SYSTEM 2:00 . t WATER HEATER 1.50 INDUSTRIAL WASTE APPROVALGAS SYSTEM OUTLETS 1.50 INSPECTION RECORD OUTLETS OVER 30 5 PER SYSTEM r le Plan check.fee.2.5%of above. See.reverse. PLUMBING PERMIT ISSUING FEE..$ TOTAL FEE APPROVALS DATE INSPECTOR'S SIGNATURE Plan check applicant UNDER SLAB WORK Name ROUGH PLUMBING Address GAS PIPING GAS VENT H City Tel. No.: OT WATER HEATER I HEREBY ACKNOWLEDGE THAT I HAYS READ THIS APPLICATION PLUMBING FIXTURES AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS TEST PLUMBING. I HERESY CERriFY THAT I AM PROPERLY REGISTERED ANRIOR UTILITY CO.NOTIFIED LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF `, CALIFORNIA OR THAT i AM THE LEGAL OWNER OF,A INTEND TO RESIDE IN.THE ROVE DESCRIBED RESIDENTIAL PRO FINAL SIGNATURE. .LACK R. ALLEN, SUPERVISIN CHANICAL ENG'R. OF PERMITTEE PERMIT VALIDATION cK. M.O. CASH PLAN CHECK VALIDATI CK. M.O. CASH L 0 6 2 .1. M .Jnr 17 5 4.7 5 N ,