The URL can be used to link to this page

Home My Public Portal About6019 AGNES AVE_Plumbing__ 76A667��+ CE 817(REV.11/78) LLLSSS i APPLICATION FOR PLUMING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING p (� C- b' f S ` -C. NUMBER FIXTURE OR ITEM @ FEE ADDRESS LOCALITY le- ,3 WATER CLOSET Q O NEAREST BATH TUB 3 QV CROSS ST. ff SHOWER OWNER MAIL �% �i / LAVATORY ADDRESS �• V i / f' SINK CITY '7e 14 , TEL.NO. DISHWASHER CONTRACTOR 'Jr,7777 CLOTHES WASHER ADDRESS SWIMMING POOL RECEPTOR CITY TEL.NO. LAWN SPRINKLER SYSTEM STATE LIC. WATER HEATER 31vo LICENSE NO. CLASS GAS SYSTEM OUTLETS OQ APPROVALS DATE INSPECTOR'S SIGNATURE OUTLETS OVER UNDER SLAB WORK 5 PER SYSTEM ROUGH PLUMBING C �' GAS PIPING GAS VENT 2i HOT WATER HEATER PLUMBING FIXTURES GAS TEST /7 �� c9® �� ub Plan check fee UTILITY CO.NOTIFIED PLUMBING PERMIT ISSUING FEE$ 00 TOTAL FEE ee FINAL Plan check applicant PLAN CHECK VALIDATION Nome Address City Tel.Na. 2 7 8 3.7 A I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES # O O O O o 5 AND STATE LAWS REGULATING PLUMBING. PERMIT VALIDATION q. I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS �'%00 ��U IA OR THAT I AM THE LEGALROWNERLOS OF.ANDANGELES INTENDCOUNTY O RES�IDESTATE HE A CALIF IDE CR BED RESIDENTIALq (� PROPERTY. / 1. 1 9—79 (SIGNATURE OF PERM ITT (JN DISTRICT NO. - 1RF0CES INDUSTRIAL WASTE APPROVAL WOthatJ COMPENSATION DECLARATION ' 76A666DPW 9/89 APPLICATION. FOR PLUMBING PERMIT .,I hereby affir!n that 1 have a certificate of consent to self insure, 76A667A or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec. 3800 Lab.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company Certified copy is hereby furnished.❑ BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) 6 Certified copy is filed with the county building inspection ADDRESS VO (— department. NUMBER FIXTURE OR ITEM (, FEE LOCALITY Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK �P+AGE PARCEL permit is for one hundred dollars($100)or less.) OWNEF'��rn ��` eA. dJ n I certify that in the performance of the work for which this permit LAVATORY G 1�yv is issued, I shall not employ an MAIL p y y person in any manner so as to SINK ADDRESS (poli {les )qfQ- become subject to the Workers' Compensation Laws. 1 DISWASHER CITY l� 1 . �D µ TEL.NO.�(_0132 Date Applicant CLOTHES WASHER CONTRACTOR tL `^v w NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers' Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. I herebyaffirm that I am licensed under WATER HEATER provisions of Chapter 9 � (commencing with Section 7000) of Division 3 of the Business and STATE LIC. Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS U OUTLETS OVER DISTRICT NO. PROCESSED BY cc 5 PER SYSTEM License Number Lic.Class `O ;bb FINAL DATE s'© VALIDATION /J Contractor Date CO I am exempt under Sec. FINALBY BAP.C.for this reason Date: Plan check fee , PLUMBING PERMIT ISSUING FEE$ Signature ❑ TOTAL FEE PI check applicant SINGLE FAMILY /� �,''•_'f _,,.v�•s#: HOME OWNER-BUILDER DECLARATION Name l9 Y� I hereby affirm that I am exempt from the Contractor's License Law p for the following reason (Section 7031.5, Business and Professions Address 60 O l9 _ A vx� i Code): citLE?mi4 le., C` Tel.No.a Da I,as owner of the property,will do the work and the structure "t`_'_•F% is not intended or offered for sale (Section 7044, Business , U__ :• and Professions Code). m,1, CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the " ' f performance of the work for which this permit is issued (Sec. 3097, - Civ. C.) a�-� — •.;::�_ a 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 above-mentioned pro y for inspection pur ses. 17 /A G 5? SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date