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Home My Public Portal About6105 TEMPLE CITY BLVD_Plumbing__ WORKERS'C.VaPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 77.7", affirm'that I have a certificate of consent to self 76A667A insure, or a certificate of Workers'Compensation Insurance; CE 817(REV. 10/81) or a•certlf'ed copy (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N __mpany ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ✓ r Certified copy is filed with th county building i ec- ADDRESS J9 • /tiion de or end ` NUMBER FIXTURE OR ITEM @ FEE LOCALITY Dates a- +�� Appli4a WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION F06M WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER SHOWER (This section need not be completed if the woyyk involved by MAIL Jam' the permit Is for one hundred dollars($100)o'r less.) LAVATORY ADDRESS G. I certify that in the,performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL.NO so as to become subject to the Workers'Compensation.Laws. DISHWASHER CONTRACTO Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR s Compensation provisions of the Labor Code, you must forth- CITY. �� TEL.NO. LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE �� CLASS deemed revoked. WATER HEATER LICENSE.NO. 24 LICENSED CONTRACTORS DECLARATION DIST: .19 IQ NO. OCESSED B I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and.effect. 5 PER SYSTEM DATEL ,� V ID TION License Number —Li c.Class FIN @9 @S Contractor Date B ❑ I am exempt under Sec. 9M B.&P.C. for this reason Plan check fee Date: ► PLUMBING PERMIT ISSUING FEE$ Signature 931 3;3.A TOTAL FEE Plan check applicant # 0 0 0 0 0 5 SINGLE FAMILY HOME.OWNER-BUILDER DECLARATION. Name I o o 3 Q 5 O 1 hereby affirm that I am-exempt from the Contractor's License Law for the following reason (Section 71)31•.5, Business and Address o - 30,5056 Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the I 0 14-85 .structure is not intended or offered for sale (Section 7044, Business and Professions Code). CONST .RUCTION LENDING AGENCY i I hereby affirm that there is construction lending agencyor the performance of the work.for which this permit is issu•W (Sec. 3097; Civ. C.).. 'r Lender's Name Lender's Address .I certify that I have read this application and state thof the i above information is correct. I agree to comply with all County ordinances and State laws regulating-Plumbing, and hereby 4auorize representatives of this County to enter upon the ntioned prerty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE of .ermittee Date • COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0802220003 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: ILEGAL ID: I FEES PAID BQILDING ADDRESS: I I ON FILE I 1 6105 TEMPLE CITY BL 1 IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801748 (ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: 15385-012-009 101 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 596 GRID: J2 LOCALITY: TEMPLE CITY, Cl 1 107 BATHTUBS/SHOWERS 1.00 FIX 16.20 I ITENANT: 125 LAVATORIES/SINKS 1.00 FIX 16.20 (ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 1 145 WATER CLOSET/URINAL 1.00 FIX 16.20 102/22/08 SR 08/20/08 TOTAL FEES 76.35 1 [ (OWNER: TEL. NO: - I IFINAL DAT''- CODE: 1 MARCELLO JUDITH E 16105 TEMPLE CITY BL [ 1 J 1 ITEMP 917801748 1 IDESCRIPTION OF WORK [ I I IREPLACE LAVATORIE, BATH TUB AND WATER CLOSET I [APPLICANT: TEL. NO: I I [ SAME AS OWNER [ ISPECIAL CONDITIONS: I I [CONTRACTOR: TEL. NO: I [APPROVALS DATE INSPECTOR SIGNATURE I ISAMB AS OWNER - I I I LIC. NO [UNDER SLAB WORK I I I I IWATER SERVICE I I 1 I I IPLASTIC Y/N METAL Y/N 1 [ 1 1ARCHITECT OR ENGINEER: TEL. NO: I I [ 1 1 I - I IROUGH PLUMBING I I [ LIC. NO: i IGAS PIPING I (GAS VENT I I I [ IHOT WATER HEATER [ I [ IPLUMBING FIXTURES I I 1 I I I I I I I [LAWN SPRINKLERS I [ I [GAS TEST 1 [ [ (UTILITY COMPANY NOTIFIED[ I I [ [� I I [ IGRAY WATER SYSTEM I I I [ I I I I I I I I I I I [ I I [ IREPORT ID: DPR263 ROUTE TO: BS0508 [ 1 [ I I I [ [ COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0608250001 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: ON FILE 6105 TEMPLE CITY BL FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801748 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: 5385-012-009 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J2 LOCALITY: TEMPLE CITY, C 51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20 TENANT: TOTAL FEES 43.95 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 08/25/06 JK 02/21/07 OWNER: TEL. NO: FINAL DATE-,,, F��BY: CODE: MARCELLO JUDITH E - 6105 TEMPLE CITY BL TEMP 917801748 DESCRIPTION OPAWORN uo v GAS LINE FOR NVAC SYSTEM APPLICANT: TEL. NO: SAME AS OWNER - SPECIAL CONDITIONS: CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE SAME AS OWNER LIC. NO UNDER SLAB WORK WATER SERVICE PLASTIC Y/N METAL Y/N ARCHITECT OR ENGINEER: TEL. NO: ROUGH PLUMBING LIC. NO: GAS PIPING GAS VERT HOT WATER HEATER PLUMBING FIXTURES LAWN SPRINKLERS GAS TEST UTILITY COMPANY NOTIFIED CKV GRAY WATER SYSTEM REPORT ID: DPR263 ROUTE TO: BSO508