HomeMy Public PortalAbout5562 WELLAND AVE_Plumbing__ : WORKERS"COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
•I"hereby,affirm}'.that I have a certificate of consent to self 76AS67A rl I
insbre, or a cerlificate of Workers'Compensation Insurance, CE 817(REV.8/86) ILJI
or a certified copy thereof(Sec. 3800, Lab. C.)
f pp j� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy Noe L` Z Company t• A'?, MOtaz
Certified copy is-hereby furnished. BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS • 6 +mac
Certified copy is filed with the county building inspec-
tion.department. NUMBER FIXTURE OR ITEM ®. FEE
• LocAurr
Date Appligant WATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' `L BATH TUB '� CROSS ST.
COMPENSATION INSURANCE OWNER 144 S �V
(This section noed not be completed.if the work involved by, SHOWER p
the permit is for one hundred dollars($100)or less.) LAVATORY V ADDRESS IV Pr 4Ai Z C
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY S 6�t rrG TEL NO.Z��r Z Z®
so as to become subject to the Workers'Compensation Laws; DISHWASHER /1 '
Q CONTRACTOR 1✓ L V� A
Date Applicant CLOTHES WASHER AllADDRESS
NOTICE TO APPLICANT: If; after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY /t—CCN pad TEL.NO "71y S�IZ_�d
with comply with such provisions or this permit shall be STATE t� o, Q LIC. 7
deemed revoked.. f_ WATER HEATER /)D LICENSE NO. L T7 L G CLASS b
• LICENSED CONTRACTORS DECLARATIONV DISTRICT NO. P ED BY
1 hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS A`/yQ
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER _ J (/o �¢
and Professions Code,and my License is in full force and effect. 15 PER SYSTEM FINAL VAUDATION
l�(�'j DATE
License Number 1 ` 'sL Lic. Class C
FI C
Contractor Pc-L. `�1-Date �� u
❑ I am exempt under Sec.
B.BP.C. for this reason
Plan_check fee 6 7 6 5 A
Date: PLUMBING PERMIT ISSUING FEE$
# 0 0 0 0 0 5
Signature
TOTAL FEE
I•o o8>350
Plan check-applicant
SINGLE FAMILY 8 0 8 a 5 0 v
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am.exempt from the Contractor's License Address 0 3 3 0°8 7
Law for-the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ 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).
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
ment' ned property for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date r
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PQBLIC WORKS 9701 LAS TUNAS PL 0508 0108310003
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 DUPLICATE
PHONE: (626) 285-0488 EXT:
LEGAL 10:
BUILDING ADDRESS:
TR: 43590 LT: 1 UN: 1 FEES 5562 WELLAND AV
FEE DESCRIPTION: QUANTITY: LION: AMOUNT: TEMP CA 917802900
857350UR INFORMATION
N NEAREST CROSS STREET: LIVE OAK
01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: D3 LOCALITY: TEMPLE CITY
07 BATHTUBS/SHOWERS 1.00 FIX 16.20
TENANT:— 45 WATER CLOSET/URINAL 1.00 FIX 16.20 ISSUED ON-—PROCESSED P ON:
TOTAL FEES 60.15 08/31/01 JK 02/27/02
OWNER:
SAMSUDIN LILIS (626) 579-5283- F A D T CO
5562 WELLAND AV ®I
TEMP 917802900S R
REMOD L BATHROOM
APPLICANT:
MIKE BURNES (626) 732-6440-
800 N. GRAND AVE SPECIAL-CONDITIONS:
COVINA 91724
S-
CONTRACTOR: TEL. NO: - APPROVALS DATE INSPECTOR SIGNATURE
MR ROOTER (626) 705-3419-
800 N. GRAND AVE. LIC. NO UNDER SLAB WORK
COVINA, CA 91724 767047-C42 * >
WATER.SER ICE
ARCHITECTOR G 0: PLASTIC Y/N METAL Y/N
ROUGH'PLUMBING
LIC. NO:
S PIPING
GSVNT
HOT WATER H TER
PLUMBING FIXTURES
LAWN SPRI R
S TEST
fUTILITY COMPART-INUM
cWV
GUY OXT91t
SYSTEM
I
* ADDITIONAL DATA ON FILE
REPORT ID: DPR263 ROUTE TO: SS0508