HomeMy Public PortalAbout9831 WENDON ST_Plumbing__ VV.0'RKERS'COMPENSATIO DECLARATION (� �j n�7 �{ j��/�[� �j� �]
i:✓ 'rn20-0026 DPW 4/87 APPUCAIl N FOR ll"L�1J11�718E��t G PERMhr
I itiereby, affirm that I have a certificate of consent to se 20-0026 76A667A
sure,or a certificate of Workers'Compensation Insurance,dr a CE 817(REV.8/86)
certified copy thereof(Sec. 3800, Lab. C.) i
COUNTY OF LOS ANGELES DEPT, OF PUBLIC WORKS
-Policy No.- Company
❑ Certified copy is hereby furnished.
i FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �•��
❑ Certified copy is filed with the county building inspection ADDRESS iJT.
department. NUMBER FIXTURE OR ITEM @ F++EE/'
LOCALITY.
Date Applicant WATER CLOSET(TOILET) �J(/ NEAREST A
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. C�
COMPENSATION INSURANCE /� OWNER �/� p
SHOWER � �v I t(�! � 60_ n 1 1 IGC.YGZ. n 5)..1
(This section need not,be completed if the work involved by MAIL
the permit is for one hundred dollars(;100)or less.) LAVATORY t7 ADDRESS C1 831 WP,
I certify that in the performance of the work for Whic f er-
mWis issued, I shall not employ any pef :n a a er so SINK CITY ' TEL. NO -1155
as'to become subject to the Workers' pen �on DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER
' ADDRESS
NOTICE TO APPLICANT: If, after ma ing this Cer: icate of - SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compe CITY TEL. NO.
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. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED 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
and Professions Code, and my license is in full force and ef-. 5 PER SYSTEM FINAL VALIDATION }
fect. DATE
License Number Lic. Class O
FINAL V
tL
Conf'rcictor. " Date BY O
I—
I am exempt under Sec. V
UJCLB.BP.C. for this reason - ..�
' Plan check fee H
Date: PLUMBING PERMIT ISSUING FEE$
Signature 6
TOTAL FEE S
SINGLE FAMILY • Platn check applicant
/
HOME OWNER-BUILDER DECLARATION z.1 3 3 7 A
I hereby affirm that I am exempt from the Contractor's Liceri'se :Name
Law for the following reason (Section 7031.5, Business and
Professions Code):, Address. #. a 0 0-6 '0 5
❑ 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, ; ( 0 .2 a 5 0
Business and Professions Code). D
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for F o 0 o 2 a 5 0 50
the pSrformance of the workfor which this permit is issued
(Sec. 3097, Civ. C.). 121 6-- 8 8
Lender's Name
Lender's Address `
I certify that I have read this application and state that the D
above information is torr'ct. I r to comply with all County !
'ordinances and tate I s r lating Plumbing, and hereby
outhori repr enta es t - County to enter upon the i -
ab pe nspection rpos
� SEE REVERSE FOR EXPLANATORY LANGUAGE
N Sign ture 6W&WIttee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0105230002
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FES PAID BUILDINGSS:
TR: 11386 LT: 2 BL: A 9831 WENDON ST
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801727
ASSESSOR INFORMATION R: NEAREST CROSS STREET: GOLDEN WEST
5385-022-016 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY
07 BATHTUBS/SHOWERS 1.00 FIX 16.20
25 LAVATORIES/SINKS 1.00 FIX 16.20 ISSUED PROCESSED R S .
45 WATER CLOSET/URINAL 1.00 FIX 16.20 05/23/01 UT 11/19/01 .
TOTAL FEES 76.35 Al
OWNER: TEL. N0: FINA DAT AL BY: CODE:
MALCYNSKI TIMOTHY D;SUSAN (626) 286-1755-
9831 WENDON ST �Q`O 0
TEMP 917801727 DESCRIPTION OF WORKFY
RENEW PERMIT FOR BEDRM, BATHRM, LAUNDRYRM, & UPGRADE EXIST
PLIC L, O:
SAME AS OWNER -
PECIAL CONDITIONS:
CONTRACTOR: TEL. 0: ' a APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER
LIC. NO yUNDER SLAB WORK
WATER SERVICE
+% PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER:
- ROUGH PLUMBING
LIC. NO:
S PIPING
GAS EN
HOT WATER HEATER
- PLUMBING FIXTURES
LAWN SPRINKLERS
S TEST
UTILITYCOMPANY 0
_ '- _ f•
GRAY WATER SYSTEM
REPORT ID: DPR263 ROUTE TO: BS0508