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Home My Public Portal About6204 TEMPLE CITY BLVD_Plumbing__ * {J WORKER'S COMPENSATION of consent to 20-0026 776AS67A PW 9189 APPLICATION FOR PLUMBING PERMIT u I hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance,or a certified copy thereof(Sec.3800 Lab.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company ❑ Certified copy Is hereby furnished. / ❑ ILDING Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS department. NUMBER FIXTURE OR ITEM ® FEE LOCALITY Date Applicant WATER CLOSETiaze NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. COMPENSATION INSURANCE BATH TUBASSESSOR (This section noed not be completed if tho work involvod by the SHOWER MAPBOOK PAGE,0/6 PA.�RCEL0,'J•0 permit Is for one hundred dollars(5100)or less.) LAVATORY OWNE I certify that in the performance of the work for which this permit MAIL is issued, I shall not employ any person In any manner so as to SINK ADDRESS become subject to the Workers'Compe do Law . DISWASHER CITY TEL.NO. I IV!`/// Data 1o Applicant CLOTHES WASHER NOTICE tO APPLICANT: If, after makino this Certifi to of CONTRACTOR Exemption,you should become subject to the Workers'Compe sation SWIMMING POOL RECEPTOR ADDRESS provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION —E CITY TEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER a (commencing with Section 7000)of Division 3 of the Business and STATE LIC. GAS SYSTEM OUTLETS LICENSE NO. CLASS V Professions Code,and my license is in full force and effect. OUTLETS OVER DISTRICT NO. PROCESSED BY jr 5 PER SYSTEM pt� Q License Number Uc.Class !/ FINALVjJ DATE (, ,VALIDATION IL Contractor Date foo ❑ I am exempt under Sec. BY FINAL a "' t: BAP.C.for this reason – ^- Date: Plan check fee , �!� : Signature PLUMBING PERMIT ISSUING FEE$ �(� T)z� 2 o5 ❑ TOTAL FEECHECK r, SINGLE FAMILY Plan check applicant ��`(Ii1��G olJlj HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5, Business and Professions Address Code): City , Q Tel.N �� '33 0-3391 12/ �f'Ir�ti 1,as owner of the property,will do the work and the structure 1 M its _C 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 ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ZI nota WORKER'S COMPENSATION DECLARATION 7BAS67BADPW9/ee APPLIC ON FOR PLUMBING PERMIT I hereby atfirm that I have a certificate of consent to self Insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company ❑ Certified copy is hereby furnished. BUILDING / s� ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Aflp-D Certified copy is filed with the county building Inspection AA ee. department. NUMBER FIXTURE OR ITEM @ FEE LOCAL[ Date Applicant WATER CLOSET NEAREST CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUBO COMPENSATION INSURANCE MAPEBOOK PARCEId�Q (This section need not be completed if the work involved by the SHOWER permit is for one hundred dollars($100)or less.) LAVATORY OWNER I certify that In the performance of the work for which this permit MAIL � rjL Is issued, I shall not employ any person in any manner so as to SINK ADDRESS/?::,?L/) 1� become subject to the Workers'Compensation Laws. DISWASHER CITY 11154W& Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, atter making this Certificate of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. � I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000)of Division 3 of the Business and STATE LIC. e Professions Code,and my license is in full force and effect. LICENSE NO. SS GAS SYSTEM OUTLETS C LA (, OUTLETS OVER DISTRICT NO. EEi0CES9@D BY D 5 PER SYSTEM /. /(y`�'� — -75 J—,(/6 !� -2.2of _�I. License Number Lic.Class _ FINAL DATE Z—Z(, -(r� VALIDIIT�O�+fl=' Contractor DateIII i I*!ffL. 483.2 FINAL _ r� c 6 ❑ I am exempt under Sec. BY CHI EC .8.2°7'-' B.&P.C.for this reasonDate: ► r-��E j°) Plan check fee PLUMBING PERMIT ISSUING FEE$ _ Signature r r r TOTAL FEE r_1AM ::-Al Plan check applicant t'-�j- ' '- SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5, Business and Professions rAddress Code): 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). 000. 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, I 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 ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned property fob Inspe n oses SEE REVERSE FOR EXPLANATORY LANGUAGE 2:!;_ innntura f Parmittea Date 0 LICATION FOR PERMIT • ` DEPARTMENT OF I3tTILDING ANIS SAFIr� � "I" WBING Foil, COUNTY OFOS ANGELES WM. J. FOX. CHIEF ENGINEER , NATURE OF INSTALLATIONj'fsTa�ICT No GROUP I ZONE SFR JT d a-- •�� MallGH FIXTURED COMPLS7 DY READY POA DAIDiUY--- .� RCC91VMD T IID q it 6E6t�Pfio6 OR'Tt� gTAN4� f r. ��,�e PIA4PINt9P/tCtIOPi /4�T7� •y.�.:�'a.''��,ky�i�:��?'`',a" A AII�ICAAe NNT.O� FILL �IN �I .AVIIY NOUTLINED '•i' POR�} •N--3i"�t C ADDF [ ® /0-F fl � LOM12 ALItV ITY cpacG T. COUNTY P R I, _jrtjR r } LOCATION OF SEPTIC TANK, OR CESSPOOL M ADLAR'CS I ;.• WORTH elty a 'PEI..No. AHOt3L= COUNTY SRTTIIVICATZ R F OUTH66I A IT VN.LOS OAM I y ►6YR® I Ae9 THIT L90AL AWN Ov THE PROPERTY DESCRIBED pp A GOV EL •' b CORREC'I'ION`3 t ® � DOUTH .� k, (DESCRIPTION OF WORK f MATH TUa FURNACE 0 It�7 QHOWCCA __DIDHWA9HBR t. �.,._l..r.LAVATORY ASCRAIGYAAtCR .,• _. .KITCH&N [RINK WATER CIOFTRNER a� FLOOR__INK SAPID TRAP , gy, ' CLOP OINK FLOOR DRAIN `r •�* "s APPROVALS WACIM TRAY —URINAL WATSR CLOSET DRINKING FOUNTAIN DATE ImerecTOR a NARe ' WATER H ATER' — DSNTAL LAVATORY ROUGH PLUMBING J /� MIMT�GA9 OODA FOUNTAIN GAO PIPING OUT(, OAS WUNT : y esu; CESSPOOL +.. TOTAL NUMBER OF FIXTURIZ �® 'GEPPIC TANK �.,:., 1. , ,sCRS8W08 EPTICTANK t . .13 ,;t A. UTILITY CO. NOTIFIED I •i'':.••f�. IB�Jdflla!�Wn GS'r + e,fA • at. :, ". • 14fT ,r —' F" •M� �Ilil ire w .a