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Home My Public Portal About5301-5303-5305-5307-5309-5311 VILLAGE CIRCLE DR_Plumbing__ WORKERS'COM�PEr sATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby,affirm that I have a certificate of consent to self 78A6B7A ifu&p, or a certificate of Workers'Compensation Insurance, CE 817(REV.8/86) City of Temple City or a certified copy thereof(Sec. 3800, Lab. C.) - COUNTY OF LOS ANGELES � DEPT. OF PUBLIC WORKS Policy No. -O�CompanyG['_ F ❑ Certified copy is hereby furnished. 2226 FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 5305 Village ` e Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM ® FEE , LOCALITY Tem le Cit Appligant WATER CLOSET Date 4-1_A8 P_T1P_7"A 1 T•n fi'f A�_], NEAREST CERTIFICATE OF EXEMPTION FROM WORKERSBATH TUB.. CROSS ST. Ra I t3win Ave COMPENSATION INSURANCE ' SHOWER OWNER SUZV Gallagher (This section need not be completed If the work Involved by MAIL the permit is for one hundred dollars($100)or loss.) LAVATORY ADDRESS ame I certify that in the performance of thework for which this permit is issued, I shall not employ any person in any manner SINK CITY SE18121-447=804.9 so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR General' I: nstallation Co Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If., after making this Certificate of ADDRESS 6558 West Blvd. Exemption, subject should become suect to the Workers' SWIMMING POOL RECEPTOR p you I CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM Los Angeles 7532 541 with comply with such provisions br this permit shall be STATE LIC. deemed revoked. 1 WATER HEAD - LICENSE NO..] CLASS 3 6 LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM Q 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 FINAL VALIDATION. DATE License,N,umber 1-51-819 Lic. Class C16 j FINj4 W O_ PEC1Viffi Date 4-55 Contractor We0a BY ❑� I am exem t under Sec. r � B.BP.C. for this reason Plan check fee i Date: PLUMBING PERMIT ISSUING FEE - Signature A 8 5 a 4 q TOTAL FEE , Plan check applicant # o 0 o 0 0 5 SINGLE FAMILY r , HOME OWNER-BUILDER DECLARATION i Name 1 0,0 1 6 60 I hereby affirm that I am exempt from the Contractor's License Address Law,for-the following reason (Section 7031.5, Business and o 0 0 16505 Professions Code): City Tel. No. ❑ I, as owner of the property,.will do the work and the 1214-87 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 correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize representative his County to enter'upon the above-m ned o rty fo Inspection purposes.) SEE REVERSE FOR EXPLANATORY LANGUAGE I 4 i 'signature of PermIttW Date I' f ION WORKER'S I have a certificate of consent to 7SA668DPw9189 APPLICATION FOR-PLPERMIT 7fiA6f37A I hereby affirm that I have a certificate of consent to self Insure, I t or a certificate of Worker's Compensation Insurance, or a certified c py thereof(Sec.9800 Lab.C.) l~ COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. licy No Company i Certified copy is hereby furnished. BUILDING �J 17 ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS .J® - Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY �f �E• e Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE NASSESSOR (This section need not be completed if the work Involved by the SHOWER MAP BOOK PAGE PARCEL permit is for one hundred dollars($1.00)or less.) OWNER I certify that in the performance of the work for which this permit LAVATORY r //l AIL is Issued, I shall not employ any person in any manner so as to SINK A DRESS 45 30 6C become subject to the Workers'Com ensation Laws. tAA�_- fin( ,� ` Date •� —9� Applicants 1 ^�+� C CLOTHES WASHER DISWASHER CITY�i?� TEL.NO.�� CONTRACTU/O'/L �1 r NOTICE TO,APPLICANT: If,-aftfir making this Certificate of I T ,6 /N Exemption,you should become sulo ct to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS ? �� / provisions of the Labor Code,you must forthwith comply with such p� ✓ l provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION ,I WATER HEATER / CITY 01I�oWg TEL.NO.� '�_ I hereby affirm that I am licensed under provisions of Chapter 9 /' 02 (commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS CENSE NO. ✓ WA CLSTATE ASS Ig _JV Professions Code,and my license is in full force and effect. 1 OUTLETS OVER DISTRICT NO. PROCESSED BY It 5 PER SYSTEM G O License Number'(g�` Lic.Class, ' lot �GCe�il�eJ H ' FINALDATE _ _ l�l VALIDATION a Contractor Date J CO) FINAL Z I am exempt under Sec. BY 5 B.&P.C.for this reason FiG'C'T.F Pian check fee Date: /, ® W �L 422.'13 Signature PLUMBING PERMIT ISSUING FEE$ r�T TOTAL FEE ITEMSd� Plan check applicant U AL 42. 60 SINGLE FAMILY I_Hj„ HOME OWNER-BUILDER DECLARATION Name `'°r'j I hereby affirm that I am exempt from the Contractor's License Law i CHANGEISI for the following reason(Section 7031.5, Business and Professions Address Code): ❑ City Tel.No. I,as owner of the property,will do the work and the structurei 1�4Lil_`j€ :c is not intended or offered for sale(Section 7044, Business 0 2/ , and Professions Code). ® 8929- 1 All 10:1` CONSTRUCTION LENDING AGENCY •1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued(Sec.3097, t Civ.C.) , I ,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 Tepres ntatives of this County to enter upon the above-mentioned prope y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE anntura of Permittee nate 76A667 (CE-817) - 5/73 APPLICATION .FOR PLUMBING PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER 1 BUILDING AND SAFETY DIVISION MAKE CHECKS PAYABLE TO: FNEAREST HARVEY T. BRANDT, COUNTY ENGINEER '1' �`i5r FOR APPLICANT TO FILL IN (PRINT OR TYPE( NUMBER FIXTURE OR ITEM @ FEE OWNER oel J WATER CLOSET 1.75 �r NBaldwin MAIL j� BATH TUB 1.75 ;.' ADDRESS 30 > -in Avee .. SHOWER 1,75 CITY IA City TEL. NO. 448—,`)07 1 LAVATORY 1,75 CONTRACTOR owm [m, PlumbinFy Inc. SINK 1.75 rADDRESS 42-65 vVJ x` 65 N. &%Uwin Ave. .S I DISHWASHER 1.75 r CITY El i7U ry TEL. NO.44-1.( 8 f CLOTHES WASHER 1'75 STATE) LICENSE NO. 231741 CLASS 06-wl f) SWIMMING POOL RECEPTOR 1.75 DISTRICT NO. GROUP ZONE PROCESSED BY LAWN SPRINKLER SYSTEM 1.75 �" ' . - cV i r�. WATER HEATER 1,75 {r INDUSTRIAL r U WASTE APPROVAL GAS SYSTEM �! OUTLETS. 1.75 /1 c LLJ INSPECTION RECORD J_ OUTLETS OVER 5 PER SYSTEM .30 O CL W Plan check fee See Reverse PLUMBING PERMIT ISSUING FEE $ 3 00 TOTAL FEE �! APPROVALS DATE INSPECTOR S SIGNATURE Plan check applicant UNDER SLAB WORK Name ROUGH PLUMBING Address GAS PIPING City Tel. NO. GAS VENT HOT WATER HEATER I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES WITH ALL •COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING. GAS TEST I HEREBY CERTIFY THAT AM PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED LICENSED AS REOUI RED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY, FINAL SIGNATURE i OF PERMITTEE PERMIT VALIDATION CK. M.O. CASH PLAN CHECK VALIDATION CK. M.0. CASH dy