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APPLICATION FOR PLUMING PERMIT
COUNTY OF LOS ANGELES
TELES
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 NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM EACH FEE A01OWNER -77
WATER CLOSET $1.25 5 ,(�
MAIL
BATH TUB 1.25 t ADDRESS SDS J
SHOWER 1.25 CITY r TEL. NO.
LAVATORY 1.25 CONTRAC R '
3[NH 1.25 ADDRESS�� '�
DISHWASHER 1.25 CITY I TEL. NO.
LAUNDRY TUB 1.25 STATE LIC
LICENSE NO. 0il-q 7f CLASS
CLOTHES WASHER 1.25 DISTRICT NO. GROUP ZONE PR CESSED BY
WATER HEATER 1.50
a
GAS SYSTEM OUTLETS 1.50 INDUSTRIALWASTE APPROVAL O
OUTLETS OVER 5 PER SYSTEM .30. INSPECTION RECORD U
O
W
a
N
Z
APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT $ 2 00 UNDER SLAB WORK
ROUGH PLUMBING
TOTAL FEE GAS PIPING
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS PLICATION GAS VENT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. HOT WATER HEATER
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST .���(/�
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF,AND INTEND TO
RESIDE IN, THE ABO�SCRIBEDTIAL PP TY. UTILITY CO. NOTIFIEDSIGNATUREOF PERMITTEEr4/ FINAL ��� 2'^v
ALIDATION JACK R"ALLEN
CK. M.O. CASH SUPERVISING MECHANICAL•ENG'R.
9142- MW 16 7.2 5 N
� /\ 1. KERS' COMPENSATION DECLARATION t r
I hareby, affirm that I have a certificate of consent to self in- 20-0026 PW 4,B7 APPLICATION FOR PLUMBING PERMIT
sure,oro certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
❑ Certified copy is hereby furnished.
• FOR APPLICANT TO FILL IN(PRINT OR TYPE) - BUILDING
❑ Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM. @ FEE LOCALITY
WATER CLOSET(TOILET). /f6
Date Applicantv`'
U NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' V
COMPENSATION INSURANCE SHOWER. . OWNER t 1
(This section need not be completed if the work involved by MAIL a�t �^
the permit is for one hundred dollars ($100)or less.) - LAVATORY ADDRESS SAM� AS -ffi5vAy�7
l:--
I certifyahat in the performance of the work for which this pe -
mit is issued, I shall not employ any person my SINK ny an CITY TEL. N4+3
1'
as to become subj t to t e Workers Compes t' w DISHWASHER � ,r
CONTRACTOR M
Date Q pplicant CLOTHES WASHER ADDRES
NOTIC TOA LICA NT: If, after a g this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subje t to the Wo ers'Compo - CIT �� G /F j TEL. N ��`
sation provisions of the Labor Code, you must f mp- LAWN.SPRINKLER SYSTEM F V�
ly with such provisions or this permit shall be deemed revok- STATE �i LIC. +
ed. WATER HEATER LICENSE NO. � - CLASS C.,J
LICENSED CONTRACTORS DECLARATION DI2;4LCT NO, P SED
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ' D
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
fed Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL ct VAL ATION
15 I 65 / _ DATE O
License Number Lic. Class V
W-07
L `f1y�l� FIN
ContractorKim
0
' Date- B f O
I am exempt under Sec. �
B.&P.C. for this reason ►
Plan check fee �
e` PLUMBING PERMIT ISSUING FEE$
Signature #•.° �S j
TOTAL FEE
SINGLE rt�ECLARATION
HOME OWNER-BUILPlan check applicant
I hereby affirm that I am exempt from the Contractor's License Nameo 040.50
Law for the following reason (Section 7031.5, Business and
Professions Code): Address o o 4 0 5 0 6
DI, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044, T1 3 —8 8
Business and Professions Code). ,/ �{ �y�/�//_ ►
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�correc+j. I gr comp with all County ,
ordinances and Stat r sting PI hereby
authorize re ativ s this Cou y to ent upon the
above- d prop for inspection�p oses. 7//��g�
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee ate