HomeMy Public PortalAbout5540 BALDWIN AVE_Plumbing__ (2) •76 A 6.67—CE 817 8/68
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APPLICATION FOR PLUMBING �PERMI
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS. . . -
COLEMAN W. JENKINS. SUPT. OF BUILDING LOCALITY -
FOR APPLICANT TO FILL IN(PRINT OR TYPE) NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM EACH FEE
OWNER
WATER CLOSET 1.50 f
MAIL
BATH TUB 1.50 ADDRESS
SHOWER' 1.50 CIzi
TEL. NO. r� ��
LAVATORY 1.50 CONTRA OR
SINK 1.50 ADDRESS
DISHWASHER 1.50 CITY TEL. NO.
CLOTHES WASHER 1.50 STATE LIC
LICENSE NO. CLASS
SWIMMING POOL RECEPTOR 1.50 DISTRICT NO. GROUP ZONE PROCESSED BY
LAWN SPRINKLER SYSTEM 2.00
O
WATER HEATER .1.50 �� INDUSTRIAL
U
WASTE APPROVAL o
GAS SYSTEM OUTLETS 1.50 INSPECTION RECORD �.
OUTLETS OVER
U
5'PER SYSTEM .30 - a
v)
I
i
Plan check fee 25% of above. See reverse.
PLUMBING PERMIT ISSUING FEE $ 2 00
TOTAL FEE r �
APPROVALS DATE INSPECTOR'S SIGNATURE
Plan check applicant UNDER SLAB WORK
Name ROUGH PLUMBING
Address GAS PIPING.
City Tel.. No. GAS VENT
HOT WATER HEATER
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS TEST
PLUMBING.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO
RESIDE-IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. FINAL .
SIGNATOR JACK R. ALLEN, SUPERVISING MECHANICAL ENG-R.
OF PE IT
PERMIT VALIDATION CK. M.O. CASH
PLAN CHECK VALIDATION CK. M.O. CASH
WORKERS'COMPENSATION DECLARATION C.
/_13 A5PnPLICATION FOR PLUMBING PERMIT
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��c00opp�y��thher�reQQof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Po cy NR � . Y_ —
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county buildin inspec- ADDRESS
NUMBER FIXTURE OR ITEM @ FEE
tion department. LOCALITY
Date
Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY ' TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR ��
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR c � <� �
CITY TEL. NO�
Exemption, you should become subject to the Workers' /
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM �(9 7a
with comply with such provisions or this permit shall be, STATELIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 00
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL 7VA ATION
2 DATE
License Number 7 Lic. Class_ Q
` ��.� ® FINAL
Contractor Date (f BY
❑
I am exempt under Sec. U
B.&P.C, for this reason LLI
Plan Check fee ► 0_'
Date: PLUMBING PERMIT ISSUING FEE$ L S� ;26663A z
Signature
TOTAL FEEell) ISO # • • • • • 5
SINGLE FAMILY Plan check applicant • -,2250
HOME OWNER-BUILDER DECLARATION Name -• •2250
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and 03. 12-87
Professions Code): City Tel. No.
❑ 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.).
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-menti net property r inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date