HomeMy Public PortalAbout9924-9926 WOODRUFF AVE_Plumbing__ WORKERS'COMPENSATION DECLARATIQN
I hereby affirm that I have a7 certificate of consent 'to"self CE st (E-a0) *APPLICATION FOR PLUMBING PERMIT
insure,or a certificate of Workers'Compensation Insurance,or I r
a certified copy thereof(Sec.3800,.Lab.C.) I ` e 'fl
WC67917. West Amer. Ins. Co. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is herebyfurnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS 9924 - 9926 Woodruff
Certified copy is filed with the unty uildin��..ffns fiction NUMBER FIXTURE OR ITEM • FEE
,te ar l!� d LOCALITY Temple City
Dat' S " Applicant - .0 �f �:v 4 WATER CLOSET ° Idl
NEAREST3 BATH TUB ROWland
CERTIFICATE OF EXEMPTION.FROM WORKERS' CROSS ST.COMPENSATION.INSURANCE 1 SHOWEROWNER J. Be Weber Const. Co.... Inc..
LAVATORY MAIL
(This section need not be completed if the work involved 4 ADDRESS 5926 Temple Cit Blvd. . ems.
by the permit is for one hundred dollars ($100) or less.) 2 SINK Tem le Cit 286-2818 0
CITY P y TEL..NO. L)
I certify that in the performance of the work for which this 2 DISHWASHER W
permit is issued, I shall not employ any person in any manner CONTRACTOR OLIVAS BROS. PLUMBING CO, 0
so as to become subject to the Workers' Compensation Laws. 2 CLOTHES WASHER ADDRESS W. Ca ifornia Street v
Date Applicant SWIMMING POOL RECEPTOR d
NOTICE TO APPLICANT: If, after making this Certificate of CITY Ontario TEL.NO.984-5069 a-
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. Z
Compensation provisions of the Labor Code,you must forth- 2 WATER HEATER LICENSE NO. 415541 CLASS C-36
with comply with such provisions or this permit shall be
deemed revoked. DISTRICT NO. PR CESSED BY
2 GAS SYSTEM ,8 OUTLETS -
LICENSED CONTRACTORS.DECLARATION OUTLETS OVER LJ
I hereby affirm that I am licensed under provisions of Chapter SPE R SYSTEM
9 (commenping with Section 7000)of Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code, and my license is in full force and I DATE g&2 IF
effect.
License Number 41 5541 C-3Fi FINAL «,
Lic.Class gY _4 �
Plumbing 10-5-82 p.
Contractor Date
171 I am exempt from the licensing requirements as I am a Plan check fee f®
licensed architect or a registered professional engineer I PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, BusI 'visa
-
iness and Professions Code). TOTAL FEE s®
Li'c.or'Reg.No. Date Plan check applicant
.HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's I /address
License Law for the following reason (Section 7031.5, Busi- City Tel.No. r 6 6 5 A
ness and Professions Code):
I, as owner of the property, am exclusively contracting f X11 o'0 0 0 05
with licensed contractors to construct the project 0 0 96 Jr 0
(Section 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY -,o 0 9 6 5 0 6
I hereby affirm that there is a construction lending agency I I Q 0 5=8 G
for the performance of the work for which this permit. is
issued(Sec.3097,Civ.C.).
Lender's Name I
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-me Toned property for inspection purposes.
-Signature of Permittee Date ;
i
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS i 9701 LAS TUNAS PL 0508 0502280012
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES-PAIDBU G DD ESS:
BK: 154 PG: 12 PC: 1 9924 WOODRUFF AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801729
ASSESSOR 0 R: NEAREST CROSS STREET: AGNES
8587-031-023 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY, C
47 WATER HEATER(S) 1.00 WTH 16.20
TENANT: TOTAL FEES 43.95 ISSUED ON: PROCESSED : PLAN BY: EXPIRES ON:
02/28/05 JK 08/27/05
OWNER: TEL. N0: FINAL CODE:
EGIZIO, KAREN (626) 643-6910-
9924 WOODRUFF AV
TEMP 917801729 DESCRIPTION OF WORK
TA-r-
WATER HEATER CHANGE OUT
PP TE O:
TEKAWA (626) 515-1311-
17111 S. BROADWAY SPECIAL CONDITIONS:
GARGENA
CONTRACTOR: TEL. NO: APPROVALS DATE INSPEC OR SIGNATURE
ACTION CONTRACTORS (310) 515-1311-
17111 SOUTH BROADWAY LIC. NO UNDER S
GARDENA, CA 90248 652535BC36
WATER SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ER: TEL. 0:
ROUGH PLUMBING
LIC. NO:
S PIPING
S VENT
HOT.WATER HEATER
PLUMBINGF RS
rAgWIMONCEFS-
GAS-TEST
UTILITY COMPANY OT ED
CWV
GRAY-WATER SYSTEM
REPORT ID: DPR263 ROUTE TO: BS0508
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