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HomeMy Public PortalAbout4855 ARDSLEY DR_Plumbing__ 76A667 17 25M SETS 7-48 APPLICATION FOR PERMIT DEPARTMENT OF BUILDING AND SAFETY APPLICATION COUNTY OF LOS ANGELES WM.J. FOX. CHIEF ENGINEER PLUMBING NATURE OF INSTALLATION DISTRICT NO. GROUPI zO E PERMIT NO. s 1. ROUGH FIXTURES COMPLETE � Y' %_ f9"-d'/ . /- HEATER CESSPOOL 1-1 SEPTIC TANK RECEIVED BY READY FOR ' DATE ISSUED FIRST INSPECTION GAS M19CELLANEOU6 APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY JOB a. NAME /i _ ADDRESS W //�• ® ADDRESS LOCALITY I NEAREST C CITY lf, / TEL.No. CROSS ST. sJ.O COUNTY LICENSE NO. ©iJ"DhV -y EXPIRES 0: NAME sly C� LOCATION OF SEPTIC TANK, OR CESSPOOL a MAIL 3 ADDRESS NORTH O CITY TEL.No. 1 AM THE LEGAL POSSESSOR OF THE ABOVE LOS ANGELES COUNTY CERTIFICATE UA IFICA7°ION. v PLUMBER 1 AM THE LEGAL OWNER OF THE PROPERTY DESCRIBED ABOVE. v 3 OWNER CORRECTIONS SOUTH .J A DESCRIPTION OF WORK z v BATH TUB FURNACE L7 SHOWER DISHWASHER O LAVATORY REFRIGERATOR / KITCHEN SINK WATER SOFTENER FLOOR SINK SANDTRAP SLOP SINK FLOOR DRAIN WASH TRAY URINAL APPROVALS WATER CLOSET DRINKING FOUNTAIN DATE2 INSPECTOR'S NAME WATER HEATER DENTAL LAVATORY ROUGH PLUMBING METER_jGAS SODA FOUNTAIN GAS PIPING OUTL GAS VENTmami i CESSPOOL TOTAL NUMBER OF FIXTURES SEPTIC TANK CESSPOOL SEPTIC TANK SEWER UTILITY CO.NOTIFIED I TOTAL FEE FINAL WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I herehy affirm that I have a certificate of consent to self 20-0026 DPW 6/87 insure, ora certificate of Workers' Compensation Insurance, 76A667A or a certified copy thereof (Sec. 3800, Lab... C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No�Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS tion department. ` NUMBER FIXTURE OR ITEM @ FEE LOCALITY • _ '// / WATER CLOSET DateL Applicant NEAREST p� CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. ell:! U00 COMPENSATION INSURANCE SHOWER OWNERMV , (This section need not be completed if the work involved by MAIL ��l the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITYCIC TEL. NO.,. so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR° '" r p� Date Applicant ` CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE ' LIC. J deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETSyi P c� (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION L DATE �Z~'� ®. License NumberC i fe Lic. Class C� FINAL f,e�� OG Contractor M 1`�' ` Date BY /�/ Oi ❑ I am exempt under Sec. B.&P.C. for this reason 9 I Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE NX si. . ... Plan check applicant w, ? •• SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address Professions Code):. City Tel. No. F .`.'. 75 ❑ 1, I, as owner of the property, will do the work and the w. 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 ; JT the performance of the work for which this permit is issued - ,: l [ ^...7 (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-men 'oned'p�rty f inspection p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE G '' r Si nature o Pe ee Date