HomeMy Public PortalAbout5536 WELLAND AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 76A6a7A
I hereby affirm that I have a' certificate of consent to self CF-817112-801 APPLICATION FOR PLUMBING PERMIT
insure,or a certificate of Workers'Compensation Insurance,or i
a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.549301Company State Fund �. �,
Certified copy is hereby furnished. �U�/ _ /� FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING 5536 Welland Ae
ADDRESS
® Certified copy is filed with the cou y building inspection NUMBER FIXTURE OR ITEM • FEE
ae ent. WATER CLOSET LOCALITY Temple City
Date —lApplican NEAREST Lige Oak
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER Mary Reynolds
MAIL
(This section need not be completed if the work involved LAVATORY ADDRESS P.O. BOX 973
by the .permit js for one hundred dollars ($100) or less,) SINK a
CITY Monrovia TEL.NO. 0
I certify that in the performance of the work for which this DISHWASHER V
permit is issued, I.shall not employ any person in any manner CONTRACTOR Ben Walker Plumbing
so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER ADDRESS 629 W. Hillcrest 0
Date Applicant SWIMMING POOL RECEPTOR 0
NOTICE TO APPLICANT: If, after making this Certificate of CITY Monrovia TEL.NO. 358919
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE 182665 N
Compensation provisions of the Labor Code,you must forth- LIC NSE NO. CLASS C-36 Z
with comply with such provisions or this permit shall be 1 WATER HEATER 31.00
deemed revoked. GAS SYSTEM OUTLETS DIST T NO. �CESSE BY
LICENSED CONTRACTOR'S DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code,and my license is in full force and DATE
effect.
License Nqtuber 182665 Lic.Class C-36 FINAL
BY
(ontrac e$ate 10-14-81.
❑ c--
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or .a registered professional engineer PLUMBING PERMIT ISSUING FEE$ 7.00
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE 10.00
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name 1 7 3 b A
I hereby affirm that I am exempt from the Contractor's Address # o o a o o 5
License Law for the following reason (Section 7031.5, Busi- City Tel.No.
ness and Professions Code): 2 o 0 1 0 Q 0
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project I o o. 0 1 Q (� 3:
U
(Section 7044,Business and Professions Code).
1028-81
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
i
i issued(Sec.3097,Civ.C.).
.,Lender's Name
,Lender's Address I i
I certify that .I have read this application and state that the
above information is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the.
abov - entioned property for inspection purposes. I
S' n re'" Perm' e � Date r
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1003090001
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS: I
ITR: 29825 UN: 8 I I 5536 WELLAND AV 8 I
I FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( TEMP CA 917802931 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: LIVE OAK I
18573-019-034 101 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 597 GRID: D3 LOCALITY: TEMPLE CITY, Cl
1 107 BATHTUBS/SHOWERS 1.00 FIX 16.20 I I
TENANT: TOTAL FEES 43.95 ISSUAD ON: PROCESSED BY: PLAN BY: EXPIRES ON:
103/09/10 SR 03/09/11
JOWNER: TEL. NO: I (FINALE FIN ^HY: CODE: I
IMICHAEL VILLASENOR (626) 379-1316- I 1 ��/� �(
15536 WELLAND AV 1 1 (I\\ 1
(TEMP 917802931 IDESCRIPTION OF WORK 1
I IREPLACE BATH TUB AND VALVE ASSEMBLY IN EXISTING LOCATIONS
I I . I I
(APPLICANT: TEL. NO: I I I
IRANDY COLE (619) 402-0828- I 1 1
IPO BOX 711564 ISPECIAL CONDITIONS: I
ISANTEE, CA 92072 I I
ICONTRACTOR: TEL. NO: I JAPPROVALS DATE INSPECTOR SIGNATURE I
JUS REMODELERS INC. (626) 333-2001- 1 1 1
1345 CLOVERLEAF DR #B LIC. NO I JUNDER SLAB WORK I I I
[BALDWIN PARK CA 91706 768707 C36 I I I I
I I WATER SERVICE
I 1 PLASTIC YIN METAL YIN I I 1
JARCHITECT OR ENGINEER: TEL. NO: I I I
1 - I 1ROUGH PLUMBING
I LIC. NO: i I I I
J� P_PING
1-1
I I IGAS VENT I I
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I 1 (HOT WATER HEATER J 1 I
I IPLUMBING FIXTURES I I I
I ILAWN SPRINKLERS I I I
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I IGAS TEST I 1 I
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UT LITY COMPANY NOTIFIED
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I I I CWV I i I
J I IGRAY WATER SYSTEM I I I
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I IREPORT ID: DPR263 ROUTE TO: BS0508 1 I I 1
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