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Home My Public Portal About9523 BLACKLEY ST_PLUMBING_11/4/2015_COUNTY OF IAS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT-OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1511040013 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: ILEGAL ID: FEES PAID BUILDING ADDRESS: ITR: 17190 LT: 9 1 1 9523 BLACKLEY ST ]FEE DESCRIPTION: QUANTITY: DOM: AMOUNT: TEMP CA 917803143 (ASSESSOR INFORMATION NUMBER: I INEAREST CROSS STREET: 8590-005-011 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY CAI I 107 BATHTUBS/SHOWERS 2.00 FIX 32.40 1 ITENANT: 13 DISHWASHERS) 1.00 FIX 16.20 ISSUED ON: PROCESSED BY: PLAN BY: 1 125 LAVATORIES/SINKS 2.00 FIX 32.40 111/04/15 SR T 1 145 WATER CLOSET/URINAL 1.00 FIX 16.20 1 TOWNER: TEL. NO: 160 DW REPAIR OR ALTER 1.00 SYS 16.20 TFINAL DATE FINAL BY: CODE: HOFELING LAWRENCE L;MARJORIE J -I TOTAL FEES 141.20 T 19523 BLACKLEY ST TEMP 917803143 i*.AJf(AJ DWS/ -M5 I)L / N 10 `� IDESCRIPTION OF WORK BATHTUB/SHOWER, LAVATORIE, SINK, WATER CLOSET AND DRAIN/VENT ryi /_anDP rj. %.t fnIff n�. 1. ). (AND DISHWASHER TAPPLICANT: TEL. NO: �✓// (JjLf-S{J,j�•'(�(/\(¢/1er �J( j /vif^1 V/ V UYV �/ IREVIVO, INA (818) 510-1072- T 1 T 118600 COLLINS ST. ISPECIAL CONDITIO )TARZANA CA 91356 )CArinto f°,'!i CONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE (UNITED DESIGN BUILDERS INC (800) 608-1360- 1 11112 MONTANA AVE #535 LIC. NOT ` L�UNDER SLAB WORK SANTA MONICA, CA 90403 674543 '?[r11 (WATER SERVICE T PLASTIC Y/N METAL Y/N (ARCHITECT OR ENGINEER: TEL. NO: - IROUGH PLUMBING LIC. NO: 1 GAS PIPING T )GAS VENT I I I IHOT WATER HEATER � � I PLUMBING FIXTURES (LAWN SPRINKLERS T ) GAS TEST I I (UTILITY COMPANY NOTIFIED) I I I� I I I 1 )GRAY WATER SYSTEM EXPIREqPERMIT EXPIRES 180 DAYS IF I ) 11) WORK DOES NOT COMMENCE, OR 12) WORK IS SUSPENDED OR ABANDONED, OR 13) FAILS TO OBTAIN CODE REQUIRED INSPECTION 1 ) T )REPORT ID: DPR263 ROUTE TO: BS0508 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 L) 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 Contra or pursuant to the Contractors' State License Law). L I am exem{ t 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 which I must have resided for at least one year prior) to completion of the improvements covered by this permit, Innot legally sell a structure that I have built as an If 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.leciinfo.ca.aovlcalaw.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. +cV� 4� // cense Class License No. I-AatellIMContractor Signature WORKERS' COMPENSATION 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. mI have and will maintain workers' compensation ance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My _Workers' sy11 ti Insurance carrier and policy u�� rub@r %13 Carder Policy Number Expiration 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' compensation provisions of Section 3700 of the Labor Code, I shall forthwit comply with those provisions -1114�2t� IS re 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 AV JOB ADDRESS 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 ❑ N o ❑ 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 ❑ N o ❑ 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 and state laws relating to building construction. I authorize representatives of this county to enter the above -identified property for inspection purposes. Signature of perry Owner or Authorized Agent —NZ3 ate 11 116