HomeMy Public PortalAbout6046 AGNES AVE_Plumbing_5/9/1979_ A ,
76A667
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►�' APPLICATION FOR P'LUMB11 1G PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN(PRINT OR1TYPE) BUILDING
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NUMBER FIXTURE OR ITEM ® FEE ADDRESS
�QL�S L i
WATER CLOSET LOCALITY
NEAREST
BATH TUB CROSS ST
SHOWER x OWNER 'v l ( EI_-.5 Djj
LAVATORY MAIL � ll
ADDRESS
SINK CITY ,�,O -Fie TEL NO 2 JlV�6Y
DISHWASHER CONTRACTOR 11�� 7
CLOTHES WASHER ADDRESS ? ,9 9
SWIMMING POOL RECEPTOR J
CITY TEL NO 4.3to 2-�Z
AWN SPRINKLER SYSTEM TATE J7LIC
/ 7-0
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WATER HEATER LICENSE NO 3 1 C ASS C.-- 1
GAS SYSTEM OUTLETS A APPROVALS DATE INSPECTOR S SIGNATURE
OUTLETS OVER UNDER SLAB WORK
5 PER SYSTEM ROUGH PLUMBING
GAS PIPING
O
GAS VENT
09
HOT WATER HEATER
PLUMBING FIXTURES
GAS TEST /Z
Plan check fee IUTILITYCO NOTIFIED
PLUMBING PERMIT ISSUING FEE$ 7.00
a
TOTAL FEE
D FINAL �o j ' ✓ ,..
Plan check applicant PLA
IN CHECK VALIDATION
Nome
,
Address (�j L0
City Tel No �z3179 `%_^ "/- '
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATEa�
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
AND STATE LAWS REGULATING PLUMBING bPERM T VALIDATION
�J_ >_ 4 2 6 7 q
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS _tjp;f •C•�µ'e'�y
REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE A� I ,_= H 0 O 0 O O J
LEGAL OWNER OF AND INTEND TO RESIDE IN T VE DESCRIBED RESIDENTIAL ®�o v� ���1"8'i_M
PROPERTY .m,,. / ROD 2 0 0 1000
SIGNATURE q'I //��
OF PERM( 0 a 091 O L/0 ca
DISTRICT NO� PRO SED BY 05 O 97`7 9
INDUSTRIAL
WASTE APPROVAL
I
I
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) '
ora certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES 7-, C BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING O ,t / C-
Certified copy is filed with the county building inspec ADDRESS !V
tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY G
Date Applicant f ` WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars ($100)or less ) IL
f LAVATORY �` ADDRESS d b
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY .®/C' e TEL NO Z
so as to become subject to the Worke p nsati Laws ��CC
^29 gy DISHWASHER CONTRACTOR
Date Appl is CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after*41�Aaking this Certificate of
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR CITY TEL NO
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM
17
with comply with such provisions or this permit shall be ISTATE LIC
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PRKESSEQOBY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM / OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER >,
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL VALIDATION 91.
DATE O
License Number Lic Class V
FINAL 09
Contractor Date BY 0
V
� ❑ I am exempt under Sec w
N
B 8P C for this reason
Date
Plan check fee 1001, Z_
PLUMBING PERMIT ISSUING FEE$
Signature � 9 8 t�7
TOTAL FEE
Plan check applicant 4 o'o o o o 5
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Nameswki r �C S�"� 2'o fo 3 4 5 Q
j hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and Address N, jF5 e o o 3 4,1 0 CE
Professions Code) CityTel No Q 3 2 1 _ IL ~
I as owner of the property will do the work and the
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 )
Lenders 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 jaw regulating Plumbing and hereby
authorize entativ sof this County to enter upon the
abov ntio d pr e y for nspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
S na re of Permittee Date /-/