HomeMy Public PortalAbout6009 AGNES AVE_Plumbing__ '8 17 25M SETS'B 46 i I 1 APPLICATION FOR PERMIT
- DEPA Mft OF BUILDING AND SAFETY
COUNTY OF LOS ANGELES �`�� ��� I
Wm J FOX CHIEF ENGINEER
NATURE OF INSTALLATION DISTRICT GROUP1 ZONE PERMIT
ROUGH FIXTURES COMPLETE —/ V-5 /;2<7'READY I
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HEATER CESSPOOL I I SEPTIC TANK RECEIVED BY FIRST INSPFECTION /DATE ISSUED,
AS' MISCELLANEOUS C✓ ���y J
APPLICANT FILL,/ IN HEAVILY OUTLINED PORTION ONLY
E NAM i l �aA /^� IN JOB
ADDRESS _?.0 S_ /. ggmZ
m gADDRESS A E� . LOCALITY A
p`I, CITY PI$[ b/a TEL No ,/� NEAREST v
? A CROSS ST �/fe�o G mss.
COUNTY _ ✓ i!� / �C
CERT No EXPIRES m NAME / / }�
LOCATION OF SEPTIC TANK, OR CESSPOOL = MAIL
NORTH 3 ADDRESS
o
CITY TEL No _
I AM THE LEGAL POSSESSOR OF THE ABOVE LOS
ANGELES COUNTY CERTIFICATE OF QUALIFICATION
PLUMBER
I AM THE LEGAL OWNER OF THE PROPERTY DESCRIBED
ABOVE
3 OWNER /
CORRECTIONS
SOUTH
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DESCRIPTION OF WORK a
Z
BATH TUB FURNACE U'
0:HOW ER DISHWASHER 0
/ e LAVATORY REFRIGERATOR
KITCHEN SINK WATER SOFTENER
FLOOR SINK SAND TRAP
SLOP SINK FLOOR DRAIN
ASHTRAY URINAL APPROVALS a
WATER CLOSET DRINKING FOUNTAIN DATE INSPECTOR S"ME
WATER HEATER DENTAL LAVATORY ROUGH PLUMBING I 41L I
METER.-�f GA8 SODA FOUNTAIN
OUn GAS PIPING I �g
GAS VENT
eeAA�� CESSPOOL I
TOTAL NUMBER OF FIXTURES cp� SEPTIC TANK ( I
CESSPOOa__k_ SEPTIC TANK ":J-CJ
SEWER
S �
TOTAL FEE � /_ uTILtTY CO NOTIFIED
/ �� FINAL
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby,affirm that I have a certificate of consent to self in- 20-0026 DPW 4/90
76A667A
`sure,or o certificate of Workers'Compensation Insurance,ora
certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Fj Certified copy is hereby furnished. '
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING f
Certified copy is filed with the county building inspection ADDRESS ('JCO t.bly
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET(TOILET)
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' I
BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER e-
(This section need not be completed if the work involved by MAIL11
Ir
the permit is for one hundred dollars(;100)or less.) i 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 / ` i t TEL. NO �1
as to become subject to the Workers' Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant -CLOTHES WASHER ADDRESS
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 SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS _ _
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER v ��ll`G'c _
and Professions Code, and my license is in full force and-ef- 5 PER SYSTEM FINA "Vi4i11�ATION
fect. HOSE BIB DAT qA _-'
License Number Lic. Class _ _ %y i 0
FINAL
I i1t � C)
Contractor Date BY r �'
I am exempt under Sec.
B.BP.C. for this reason ► _ i ; a
Plan check fee � _
Date: PLUMBING PERMIT ISSUING FEE$ L� 0
Signature •
TOTAL FEE �`
SINGLE FAMILY 1 `-)'ll'I`)-01:01(�I n%� r
HOME OWNER-BUILDER DECLARATION Plan check applicant _yL_:
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
I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
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 oil.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
abo - entioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign(/re re of Permittee Date