HomeMy Public PortalAbout6208 TEMPLE CITY BLVD_Plumbing__ •, "ICER'S COMPENSATION DECLARATION 20-0025 DPW 8/88 APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self Insure, 78A557A
or if certificate of Worker's Compensation Insurance, or a certified 1
copy thereof(Sec.3800 Lab.C.)
❑
Policy No. Company ®AM ICA0114� COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
•
Certified copy is hereby furnished. / /� p� f�
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS t/Q go lS T�� � �
Ce Ified py is filed with th un building ins ction
d artme t. NUMBER FIXTURE OR ITEM ® FEE LOCALITY
Date Ap scant WATER CLOSET NEAREST
CROSS ST. L U'LCI
CER IFICATE O EMPTION FROM WORK S' 1 BATH TUB ASSESSOR
COM NSATION INSURANCE
(This section need not a completed If the work i volved by the SHOWER MAP BOOK PAGE PARCEL
permit is for one hun ed dollars($100)or less.) OWNER POS •` _l� _d �� '
I certify that in the p formance of the work for which this permit LAVATORY // -�-t.J
is issued, I shall not mploy any person in any manner so as to SINK ADDRESS t:/�/U
become subject to the Workers'Compensation Laws. /
DISWASHER CITY J,e� ca c,'47, TEL.NO."
Date Applicant CLOTHES WASHER . R
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR OL.,t� S CE
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS�� �� 6.,-, Q 1,( .
provisions of the Labor Code,you must forthwith comply with suchAJ 10
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARf7�(�t/)DECLARATION Mex..,. TEL.NO. 3 Z) CL
I hereby affirm that I am licensed under provisions of Chapter 8 WATER HEATER - v` Al- 7�
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS CENSE NO. > ?j g CLASS I TE LIC. Q
Professions Code,and my license is in full force and effect. OUTLETS OVER DISTRICT NO. PR Q
'
3w5 PER SYSTEM ✓� Q
ns Num r U0.Class CJ
� FINALV
-11M i4 DATE 0_ 7_g , 1 ►LI ATION w
a
ContreP+Ucto � Date L% U]
r-1I am xempt under Sec. FINBY AL ,33011 41O: '3'.
B.BP.C.for this reasonr'-
Plan check fee , 1. �t tffiJ
Data. PLUMBING PERMIT ISSUING FEE$ Q TOTAL�TAL 41 =E35
Signature r. i 1 u V+5
TOTAL FEE �J/ CHECI/,
❑ SINGLE FAMILY Plan check applicant '.;HflNG
HOME OWNER-BUILDER DECLARATION NameU L a
I hereby affirm that I am exempt from the Contractor's License Law 0.
for the ;(following reason (Section 7031.5, Business and Professions Address
Code): city C1—,J Cr Tel.No.a3-IT7- O6&,C 6179 1 PrI 42 ;7
❑ I,as owner of the property,will do the work and the structure
is not intended or offered for sale(Section 7044, Business I ,
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 ,
ZtWtion_
orrect. 1I agree o comply with all County ordinan s
ws regulating lumbing and herebyauth of this Coun nt Pon the above- SEE REVERSE FOR EXPLANATORY LANGUAGE
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f n*I:.e ..e ee....INee I r1sNe
• j COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS I PL 0508 0106260016
BUILDING AND SAFETY / LAND DEVELOPMENT I. TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LGA ! BUILDINGDRESS:
ON FILE 6208 TEMPLE CITY BL
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801749
ASSESSOR N OR 0 BER: G NEAREST CROSS STREET: LONGDEN
5385-016-021 01 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 596 GRID: J2 LOCALITY: TEMPLE CITY
51 LOW PRS GAS 5 OUTLET 1.00 SYS 16.20
TOTAL FEES 43.95 ISSUED ON: PROCESSED BY: P PIR S •
06/26/01 UT 12/23/01 .
1
OWNER: TEL. O: FINALS DATEN CODE:
PACIFIC ACKWORTH FOUNDATION - g fir
1020 EL SUR AV I
ARCD 910064529 SC IPT 0 0 WO
t GAS METER
APPLICANT: 1
VAN ALLEN (818) 352-7753-
10264 TUJUNGA CANYON SPECIAL CONDITIONS:
TUJUNGA, CA r---
�G ��S e
CONTRACTOR: TEL._N U: ,� S `"- �/�\�� APPROVALS DATE INSPECTOR SIGNATURE
VAN ALLEN PLUMBING (818) 352-7753-
10264 TUJUNGA CYN BLVD LIC. NO UNDER SLAB WORK
TUJUNGA, CA 91042 620656C36 *1 � ' p
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR E GINE R: TEL. NO: \,t, ROUGH PLUMBING
~ q
LIC. NO. f I j i `:� , ti'r,
GAS PIPING
HOT WATER-IfEATER
L ING FIXTURES
------ � - --- .,•,-� '��,----'-/ -� LAWN SPRINKLERS
117N GAS TEST
E i,��l ..,l��y�• UTILITY COMPANY NOTIFIED'
cwv
ed bice h GRAY WATER SYSTEM
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* ADDITIONAL DATA ON FILE
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REPORT ID: DPR263 ROUTE TO: BS0508