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Home My Public Portal About6038 AGNES AVE_Plumbing__ a 7GA667A (CE 8176) 4/77 APPLICATION FOR PLUMBING PERMIT BUILDIN D SAFETY DIVISION FOR APPLICANT TO FILL IN(PRINT OR TYPE( BUILDING NUMBER FIXTURE OR ITEM ® FEE ADDRESS WATER CLOSET LOCALITY BATH TUB NEAREST CROSS ST SHOWER OWNER / LAVATORY MAIL ADDRESS .►/r/S SINK CITY TEL NO DISHWASHER CONTRACTOR CLOTHES WASHER ADDRESS SWIMMING POOL RECEPTOR n LAWN SPRINKLER SYSTEM CITYSTATE LIC TEL NO�A� 3�1 WATER HEATER LICENSE NO T CL CLASS C.= 3 C / GAS SYSTEM OUTLETS DISTRICT NO�y UP LZQNE CESSED UY OUTLETS OVER v v - CD 5 PER SYSTEM INDUSTRIAL C.2 WASTE APPROVAL ix INSPECTION RECORD A O Plan check fee PLUMBING PERMIT ISSUING FEE$ TOTAL FEE Plan check applicant AP Name DATE )MSPECTPR S SIGNATURE UNDER SW WORK S' Address ROUGH PLUMBING City Tel No GAS PIPING 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE GAS VENT THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING HOT WATER HEATER I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED A LICENSED AS PLUMBING FIXTURES REQUIRED BY LOS ANGELES COUN AND STATE OF CALIFOR ORT T I AM THE GAS TEST LEGAL OWNER OF AN NTEND SIDE INT ABOVE DES BED R SIDENTIAL PROPERTY UTILITY CO NOTIFIED SIGNATURE / OF PERMITTEE ° FINAL D�TN �O �CEO ��ayWPLAN " PERMIT VALIDATION cK Mo CASH JUL 14 5 D 2 5.0 6�-POLICY HOLDER d/ C� POLICY NUMBER VUC WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure or a certificate of Workers Compensation Insurance CE 817(REV 10/81) or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company Certified copy is hereby furnished ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING � � � ,� N ��`-, �'Zi, Certified copy is filed with the county building inspec ADDRESS (`if tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS 1 BATH TUB CROSS ST COMPENSATION INSURANCE SHOWER OWNER ff u�• >� C (This section need not be completed if the work Involved by MAIL the permit is for one hundred dollars ($100)or less ) I LAVATORY i' ADDRESS L I certify that in the performance of the work for which this permit is issued I shall not employ any person in any manner SINK CITY C TEL NO)y7� so as to become subject to the Workers Compensation Laws DISHWASHER CONTRACTOR Q-1 )+)I L Lz � Date5// Applicant CLOTHES WASHER ~ ADDRESS NOTICE TOA PLICANT If after ma mgt is Certificate of 0G 2 3 Z I Y Exemption you should become sub ect to the Workers SWIMMING POOL RECEPTOR P Compensation provisions of the Labor Code you must forth - LAWN SPRINKLER SYSTEM CITY ^S A y0 M P-A-)N -� TEL NO r) i :-�if 73 with comply with such provisions or this permit shall be STATE LIC �- L deemed revoked / WATER HEATER _� LICENSE NO 3 LLf C7 S O CLASS C 3 LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER /N/*r and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL DATE�f VALIDATION u License Number 3 S :3 Lic Class C 3 k, oe FIN O 1 Contractor Date 7 1sr 4 B ElI am exempt under Sec � B&P C for this reason Plan check fee Date PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant SINGLE FAMILY �G 2 0 5 A HOME OWNER BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor s License $E{0 0 0 010 55 Law for the following reason (Section 7031 5 Business and Address Professions Code) r City Tel No 1 46,50� ❑ 1 as owner of the property will do the work and the to 0 1 0 4 6 5 0:C15 structure is not intended or offered for sale (Section , 00 17-84 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 ► 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 property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Qn.. c C�: 7 r Signature of P rmittee Date