HomeMy Public PortalAbout9712 WINDSOR LN_Plumbing__ WORKERS'COMPENSATION DECLARATION APPUCATION FOR PLUMBIN Lf"ERNT
I hereby'affirm that I have a certificate of consent to self 76A667A
insure,Aka certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
4;a,certi ed copy thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND/SAFETY Qf
Policy Non7862379Raompany Friamnnt
Certified copy is hereby furnished.
® FOR APPLICANT TO FILL IN PRINT OR TYPE BUILDING
Certified copy is filed with the county building inspec- ( ) Windsor Lane
ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Dare 10-16-86 Appli4ant Owen BrOS Plba. WATER CLOSET Tem le Cit
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
112—
COMPENSATION INSURANCE SHOWER OWNER Owen Development
(This section need not be completed if the work involved by
MAIL
the permit is for one hundred dollars($1100)or less.) ' LAVATORY 20 ADDRESS 2035 S. Myrtle Ave.
I certify that in the performance of the work for which this
permit is issued,1 shall not employ any person in any manner SINK CITY Monrovia TEL' NO359-3211
so as to become subject to the Workers'Compensation Laws.
/ DISHWASHER to
CONTRACfOIeri Bros. P1LIIi$Jing, Inc.
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 4265 N. Baldwin Ave.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
-Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM - CITY El Monte TEL. NO. 443-007$
• with comply with such provisions or this permit shall be STATELIC
NO. 23l 741 LICA55 C36-20
deemed revoked. WATER HEATER
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS U Q r
(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 -^ a
License Number 231 741 Lic. Class C36-20
C
Contractor Mmn RrnG_P1 hQ_Date 1 n-1 fi—SA
❑ 1 am exempt under Sec. C1
B.&P.C. for this reason 111Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ ® Cr
Signature
TOTAL FEE rte.
r
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and ti
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). .,,9 58 Q 5 A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for # 0.0 0 0 0 5
the performance of the work for which this permit is issued I o o94,50
(Sec. 3097, Civ. C.).
o o 94,50
Lender's Name
I Q29=8i5
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
4ord' nces and State laws regulating Plumbing, and hereby
ize r resentatives his County to enter upon the
-m edpro ty inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ure of Permitt Date
C
I
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0302050013
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
L L D• F55S PAID BUILDING
TR: 43189 LT: 4 9714 WINDSOR LN5•
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803949
ASS5SSOR-INFORMATION NUMBER. NEAREST CROSS STREET: GOLDEN WEST
8589-019-038 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY
13 DISHWASHER(S) 1.00 FIX 16.20
TENANT: TOTAL FEES 43.95 ISS090 O PROCESSED S 0 :
02/05/03 JK 08/04/03
OWNER: TEL. N0: FINA DATE F Y: CODE:
TRINH;CHAU (626) 579-4789-
9714 WINDSOR LN
TEMPLE CITY 91780 D SCR ON RK
C/O DISHWASHER
APPLICANT:
APPLIANCE INSTALLERS INC (562) 986-5511-
3823 INDUSTRY AVENUE SPECIAL CONDITIONS:
LAKEWOOD 90712
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
APPLIANCE INSTALLERS INC. (562) 986-5511-
3823 INDUSTRY AVENUE LIC. NO UNDER SLAB WORK
LAKEWOOD CA 90712 594252C36
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT 0 ENGINEER: 0:
i� ROW PLUMBING
LIC. N0:
GAS 41PING
GAVENT
II AOT WATER HEATER
�I P1UM. I G FIXTURES
II� LAWN SPRINKL RS
S S
UTILITY COMPANY 0 D
C V
GRAY WATER SYSTEM
REPORT ID: DPR263 ROUTE TO: BS0508