HomeMy Public PortalAbout9828 Garibaldi Ave_Plumbing_3/30/2015_'
ON
FILE
(PORT ID: DPR263
COUNTY OF LOS ANGELES
BS0508
TEMPLE CITY N
0508
PLUMBING PERMIT
DEPARTMENT OF
PUBLIC WORKS
9701 LAS TUNAS
PL 0508 1503300023
BUILDING AND SAFETY
/ LAND DEVELOPMENT
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID:
FEES PAID
BUILDING ADDRESS:
TR: 6561 LT: 55
ON: .003
9828 GARIBALDI AV
IFEE
DESCRIPTION: QUANTITY: DOM:
AMOUNT:1
TEMP CA 917801712
ASSESSOR INFORMATION NUMBER:
I
I NEAREST CROSS STREET: GOLDEN WEST
5385-027-003
101
PERMIT ISSUANCE FEE
27.80
THOMAS PAGE: 597 GRID: A2
LOCALITY: TEMPLE CITY
164
WATER PIPNG c= 1 1/2 1.00 LIN
16.20
I_
TENANT:
TOTAL FEES
44.00
(ISSUED ON: PROCESSED BY: PLAN BY:
103/30/15 SR
OWNER:
MR. AN CHAO-
TEL.
NO:
F17JAI4 DAIX, FI BY:
CODE:
9828 GARIBALDI AV
`�,fj`
TEMP 917801712
IDE CRI PT ON OF WORK
i
IREPLACE MAIN LINE WATER TO OUSE
APPLICANT:
TEL.
NO:
I
PARTON, BRUCE
(818) 879-5002-
I
1351 TOTTENHAM CT
CONDITIONS:
OAK PARK CA 91377
I
(SPECIAL
CONTRACTOR:
TEL.
NO:
1
(APPROVALS DATE
INSPECTOR SIGNATURE
HP ASSOCIATES, INC.
(818)
879-5002-
1
1351 TOTTENHAM CT
LIC. NO
]UNDER SLAB WORK
OAK PARK CA 91377
740238
WATER SERVICE
Y/N TAL /N
ARCHITECT OR ENGINEER:
TEL.
NO:
(PLASTIC
-
IAOUGH PLUMB
V
LIC. N0:
(GAS PIPING I
VENT
]
(GAS
(HOT WATER HEATER
(PLUMBING FIXTURES
I
I i I
ILAWN SPRINKLERS I
I
I I I
(GAS TEST I I
UTILITY COMPANY NOTIFIED(
ICWV
ADDITIONAL DATA
ON
FILE
(PORT ID: DPR263
ROUTE TO:
BS0508
OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION I JOB ADDRESS
by affirm under penalty of perjury that I am exempt from
ontractors' State License Law for the reason(s) indicated
by the checkmark(s) I have placed next to the applicable
(Section 7031.5, Business and Professions Code): Any
county that requires a permit to construct, alter, improve,
ish, or repair any structure, prior to its issuance, also
as the applicant for the permit to file a signed statement
e or she is licensed pursuant to the provisions of the
rotors' State License Law (Chapter 9 (commencing with
n 7000) of Division 3 of the Business and Professions
or that he or she is exempt from licensure and the basis
i alleged exemption. Any violation of Section 7031.5 by
pplicant for a permit subjects the applicant to a civil
V of not more than five hundred dollars ($500).):
is owner of the property, or my employees with wages as
ole compensation, will do (J) all of or U portions of the
and the structure is not intended or offered for sale
m 7044, Business and Professions Code: The
ictors' State License Law does not apply to an owner of
ty who, through employees' or personal effort, builds or
,as the property, provided that the improvements are not
ed or offered for sale. If, however, the building or
,ement is sold within one year of completion, the Owner -
r will have the burden of proving that it was not built or
,ed for the purpose of sale.).
is owner of the property, am exclusively contracting with
id Contractors to construct the project (Section 7044,
iss and Professions Code: The Contractors' State License
oes not apply to an owner of property who builds or
res thereon, and who contracts for the projects with a
id Contractor pursuant to the Contractors' State License
M exemdt from licensure under the Contractors' State
ie Law for the following reason:
signature below I acknowledge that, except for my
ial residence in whicf I must have resided for at least
)ar priori to completion of the improvements covered by
rmit, I cannot legally sell a structure that I have built as an
builder If it has not been constructed in its entirety by
id contractors. I understand that a copy of the applicable
action 7044 of'the Business and Professions Code, is
ole upon request when this application is submitted or at
owing Web site: hffD://www.lecinfo.ca.cov/calaw.html.
ure of Property Owner or Authorized Agent
I hereby affirm under penalty of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, and my
license is in full force and effect.
�License Class � License No.
,,-'gate
`gate �L( ontractor Signature I "V
WORKERS' COMPENSATION
WARNING: FAILURE TO SECURE WORKERS' CO PENSATION
COVERAGE IS UNLAWFUL, AND SHALL OBJECT AN
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following
declarations:
have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
work co nsation i nc ,pa �r d policy'n r are:
Carrier Policy Number Expiration ate
Name of Agent
Phone Number
I certify that, in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to be a subject to the workers' compensation laws of
California, nd agree that, if I should become subject to the
workers' mp nsation provisions of Section 3700 of the Labor
Code, I s II fo hwith comply with those provisions
}rte
Signatur�of Applicant Date
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 at seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
Applicant (Print Name) Applicant Signature
Company Name Date
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous materials
information guide?
Yes ❑ No ❑
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ No ❑ j
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirements
under the Los Angeles County Code Title 2, Chapter 220'
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lender's Name
Lender's Address
By my signature below, I certify to'each of the following:
I am the property owner or authorized to act on the
property owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances ymfdl state laws relating to building
I authorize trepreOntatives of this county to enter the
above-identfTied Vroperty for inspection purposes.
Signaturelbf P o C
V v a6I q
or Authorized Agent
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S X H O M J I 8 S 0 d d O L N S W . t d V d S U
s a u o N M S O ' I 3 0 A I N n o o
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure and the basis
for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil
penalty of not more than five hundred dollars ($500).):
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (-/)all of or (_) portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the improvements are not
intended or offered for sale. If, however, the building or
improvement is sold within one year of completion, the Owner -
Builder will have the burden of proving that it was not built or
improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contma for pursuant to the Contractors' State License
Law).
(_) I am exempt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in whicf I must have resided for at least
one year priori to completiory of the improvements covered by
this permit, I cannot legally sell a structure that I have built as an
owner -builder If it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of'the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: htto://www.lecinfo.ca.cov/calaw.html.
Date:
Signature of Property Owner or Authorized Agent
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, and my
license is in full force and effect.
I cc/
License Class License No. 7V076 e
'>4—'Date Contractor Signature //�/1 �
WORKERS' COMPENSATIOIG DECLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION
COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following
declarations:
I have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
work s' ora nsa'on insurance carrier and policy rare:
Carrier i�c u er Expirati n Date
Name of Agent Phone Number
I certify that, in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the workers' compensation laws of
California, and agree that, if I should become subject to the
workers' co ensan provisions of Section 3700 of the Labor
Code, I sh I f rthwithtiocomply with those provisions
i5'9nat a of Applicant Date
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 at seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
Applicant (Print Name) Applicant Signature
Company Name Date
JOBADDRESS
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous materials
information guide?
Yes ❑ No ❑
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ No ❑ /
i
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirements
under the Los Angeles County Code Title 2, Chapter 220 -
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lender's Name
Lender's Address
By my signature below, I certify to'each of the following:
I am the property owner or authorized to act on the
property owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to wmply with all applicable city and county
ordinances 'and state laws relating to building
-xmte f
esentatives of this county to enter the
property for inspection purposes.
Owner or Authorized Agent