HomeMy Public PortalAbout5951 AGNES AVE_Plumbing__ 76A667 (CE 817) 4/72
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
MAKE CHECKS PAYABLE TO ADDRESS
HARVEY T BRANDT COUNTY ENGINEER LOCALIT
FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST
CROSS ST
NUMBER FIXTURE OR ITEM @ FEE
WATER CLOSET 1 75 OWNER
MAIL
BATH TUB 1 75 ADDRESS
SHOWER 1 75 CITY TEL NO
LAVATORY 1 75 CONTRACT _
i
SINK 1 75 ADDRESS
DISHWASHER 1 75 CIT TE
CLOTHES WASHER 1 75 STA LIC 7
LICENSE NO CLASS (p
SWIMMING POOL RECEPTOR 1 75
DISTRICT NO GROUP JZON.EjFROCESSED BY
LAWN SPRINKLER SYSTEM 1 75 CJ
WATER HEATER 1 75 / INDUSTRIAL
WASTE APPROVAL a
GAS SYSTEM OUTLETS 1 75 INSPECTION RECORD C.7
OUTLETS OVER
5 PER SYSTEM 30 CD
F—
V
W
C
l/7D
Z
r
Plan check fee See Reverse
PLUMBING PERMIT ISSUING FEE $ 3 00
TOTAL FEE
APPROVALS DATE INSPECTOR S SICNATU RE
Plan check applicant
UNDER SLAB WORK
Name ROUGH PLUMBING
Address GAS PIPING
City Tel NO GAS VENT
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION HOT WATER HEATER
�
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING GAS TEST
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO NOTIFIED
LICENSED AS REOU IRED BY LOS ANGELES COUNTY AND STATE OF
CALI FORN IA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO
RESIDE IN THE ABOVE DESCRIBED RESIDENTIA ROPER TY FINAL
SIGNATU RE
OF PERMITTE
PERMIT VALIDATION cK M o CASH
PLAN CHECK VALIDATION cK M o CASH
7 2 0 cZAUG -9 5 1 , 4 7 5 ®:,n
t 'WORKERS' COMPENSATION-DECLARATION
hereby,affirm that I have a certificate of consent to self in- 76A666 DPW 4/87
A APPLICATION FOR PLUMBING PERMIT
'
sure, or a CE 817 certificate of Workers'Compensation Insurance,or CE 817(REV. 8/86)
certified-copy thereof (Sec. 3800, Lab. C.j
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
❑ Certified copy is filed with the county building inspection ADDRESS
NUMBER FIXTURE OR ITEM LOCALITY
department. @ FEE
/ WATER CLOSET(TOILET)
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
l BATH TUB. CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
(This section,need not be completed if the work involved by. MAIL
the permit is for one hundred dollars ($100) or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which.this per- SINK
mit is issued, I shall not employ any person in any manner so CITY TEL. NO.
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR Q
Date Applicant / CLOTHES WASHER ADDRESS �J
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption,.you should become subject to the Workers'Compen- 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 I DISTRICT NO. OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS (1�
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER �f
and Professions Code, and my license is in full force and ef- 1 5 PER SYSTEM FINAL >_
fect. DATE / `r;; VALIDA N 0.
License Number Lic. Class 7 O
U
FINAL / ' !,
Ix
Contractor Date BY " ' O
❑ I am exempt under Sec. j W
� + LU
B.&P.C. for this reason pop. r"-
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE $
Signature TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and ;
Professions Code): Address ki
77,t;f
I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Sectiont7044, .4 7 i;'dt,;
Business and Professions Code). ► ',",.y _
_5 =nfl f
CONSTRUCTION LENDING AGENCY .-t, -
I hereby affirm that there is a construction lending agency for *''=' ''I r
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
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
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
ahoy entioned pro rt y fo inspecti fi purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ature of P rmittee Date'