HomeMy Public PortalAbout5403 WELLAND AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION
20-0026 DPW 4/87 �°
�i reb'y,"5£firm that I have a certificate of consent to self in- 76A66720-002A APPLICATION FOR PLUMBING PERMIT
iur4,or a certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86)
certified copy thereof(Sec. 3800, Lab. C.)
Policy No.100489604 Company CNA TnG (^o- COUNTY OF LOS ANGELES DEPT: OF PUBLIC:WORKS':.
•Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the county building inspection ADDRESS •5403 Welland.
department. NUMBER FIXTURE OR ITEM @ FEE - I t
LOCALITY' '
Dates Applicant—1 8-88 A Owen WATER CLOSET(TOILET) Tem •le City.,
PP Bros Pl�• NEAREST
CERTIFICATE-OF EXEMPTION FROM WORKERS' BATH TUB % r• CROSS ST.
;.,.:•'COMPENSATION INSURANCE a SHOWER OWNER Owen Development
(This section"need-not be'Completed If the work involved by MAIL • '
The permit is for one hundred dollars(5100)or less.) LAVATORY ADDRESS 2035 S. Myrtle Ave.
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so / SINK CITYMonrovia TEL. NO.359-3211
as to become subject.to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR Owen Bros. MR. Inc.
Date Applicant CLOTHES WASHER
ADDRESS
NOTICE-TO APPLICANT: If, after making this Certificate of Ex- -4265 N. Baldwin Ave.
em tion,You should become subject to the Workers'Com en- SWIMMING.POOL RECEPTOR
P Y I P CITY E1 Monte TEL. No.443-0078
sation.provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. 231 741 CLASS KXXX C36
LICENSED CONTRACTORS DECLARATION DISTRICT NO;�� PROC BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
fe a, Professions Code, and my license is in,full DATull force and ef- 5 PER SYSTEM FINA �� VALID IOIN a
0
License Number 231 741 Lic. Class C36-20 U
FIN cc
Contractor Owen BroG. 121 hg Date 5-1 8-88 BY O
I am exempt under Sec. W
IL
B.BP.C. for this reason Plan Check fee ® W
Date: PLUMBING PERMIT ISSUING FEE$ z 9 6
Signature TOTAL FEE # 0 0
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check aPP liccint (� 6 I ° 5 O
1 hereby affirm that I am exempt from the Contractor's License Name ° ° 2 0 0.5 0 c=.)
Law for the following reason (Section 7031.5, Business and
Professions Code): Address •0 525-88
❑ I, as owner of the property; will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044, \
Business and Professions Code).
•CONSTRUCTION LENDING AGENCY ® 29 6 a 7 A
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued #'o o•0 0 0 5
(Sec. 3097; Civ. C.).
.I ° 20250
Lender's Name °;° 2 0 2 5 0 c=i'
Lender's Address 0525-88
1 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
uth ize r ' s�ntatives this County to enter upon the
b e-m ed prolaj4t,
inspection purposes.
, 5-18-88 SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature of PermitteV Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 1 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 9812290016
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (818) 285-0488 EXT:
GA D: ---FEES PAID BUILDING .
BK: 207 PG: 61 PC: 1 3 5403 WELLAND AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803536
ASSESSOR ORMA 0NUMBER: 1 NEAREST CROSS STREET:
8573-016-049 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: D3 LOCALITY: TEMPLE CITY
13 DISHWASHER(S) 1.00 FIX 16.201
TENANT: TOTAL FEES 43.95 ISSUED ON: PROCESSED-BY: PLAN B EXPIRES ON:
12/29/98 UT 12/29/
OWNER: TEL. 0: FINAL DATE FINAL BY: DE:
WONG CHI-HUNG;CHEN JUI-HSIANG (818) 442-3440-
5403 WELLAND AV /`-f
TEMP 917803536 DESCRIPTION OF WORK
CHANGE OUT OF DISHWASHER
APPLICANT: L. O•
D & H SERVICE (818) 343-4009-
6029 1/2 RESEDA SPECIAL CONDITIONS:
TARZANA, CA
�h13ELES Cp
CONTRACTOR: TEL. N0: OsJ ��/,. APPROVALS DATE INSPECTOR SIGNATURE
D & H SERVICE (818) 343-4009- V
6029 1/2 RESEDA BL LIC. NO UNDER SLAB WORK
TARZANA CA 91356 704779 C36
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: 0: ./
0 MB NG
LIC. N 1111111
[L S PIPING
GAS VENT
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46��e Servfice Tho a�� < CWV
GRAY WATER MOEN
REPORT ID: DPR263 ROUTE TO: BS0508