Loading...
HomeMy Public PortalAbout4879 ARDSLEY DR_Plumbing__ 76A667A(CE817A) - 8/75 n APPLICATION FOR PLUMBING PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION MAKE CHECKS PAYABLE TO: ILDING G� �'C/ 12 y DRESS K HARVEY T. BRANDT, COUNTY E�NGIIN4 �� CALITY FOR APPLICANT TO FILL IN (PRINTTYPEARESTOSS ST. NUMBER FIXTURE OR ITEM @ FEE /n WATER CLOSET OWNER �•`�— MAIL BATH TUB ADDRESS SHOWER CITY //'�� TTEL. NO. LAVATORY CONTRACTC�/gCIFIC INSTALLERS SINK ADDRESS 10920 E. GRAND AV DISHWASHER CITY TEMPLE CITYTECA o1-707V *, CLOTHES WASHER STATLIC E LICENSE NO. �( v/ Q CLASS SWIMMING POOL RECEPTOR C� // U DISTRIX NO. ( UP N7 OC ED- BY LAWN SPRINKLER SYSTEM 15 ye-Gti mac_/ WATER HEATER INDUSTRIAL ;g WASTE APPROVAL GAS SYSTEM OUTLETS INSPECTION RECORD OUTLETS OVER 0 5 PER SYSTEM O u. Plan check fee See Reverse PLUMBING PERMIT ISSUING FEE $ TOTAL FEE (� 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 I HEREBY.ACKNOWLEDGE THAT I 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 PLUMBING. GAS TEST I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED LICENSED AS REOUI RED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT,I AM THE LEGAL O NER OF, AND INTEND TO RESIDE IN THE ABOVE DES IBE RESID N IAL PROPERTY. FINAL 7- "7 !> SIGNATURE OF PERMITTEE EMENNEEMd PERMIT VALIDATION CK. � M.O. CASH PLAN CHECK VALIDATION CK. M.O. CASH Q .. r'ti ORKERS' COMPENSATION DECLARATION - f`y—a' ' 26A667 DPW 4/87 APPLICATION FOR PLUMBING PERMIT Thereby, affirm that I have a certificate of consent to self in- 7hA667A Vure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) U certifjec)so. trhe're'o`f (Sec. 3800, Lab.,C. Po icy N7j/n Company COUNTY OF LOS.ANGELES DEPT. OF PUBLIC WORKS Certified copy is hereby furnished ` ` FOR APPLICANT TO FILL IN(PRINT OR TYPE). BUILDING t" n �/ / ,CU !� Certified copy is filed with the county building inspection ADDRESS NUMBER FIXTURE OR ITEM LOCALITY department. @ FEE Date 'licant WATER CLOSET(TOILET) PP NEAREST, CERTIFICATE OF EXEMPTION FROM WORKERS' BATH'T.UB CROSS ST.' COMPENSATION INSURANCE SHOWER OWNER sf/ (This section need not be completed if the work involved by MAIL sv J the permit is for one hundred dollars ($100)or less.)- LAVATORY- ADDRESS ® ! . I certify that in the performance of the work for which this per- SINK mitisissued, 1 shall not employ any person in any manner so CITY _ TEL. NO. 1-31 as to become subject to the Workers'Compensation Laws. DISHWASHER A CONTRACTOR / � � r Date Applicant CLOTHES WASHER ADDRESS c� vCC,�� NOTICE TO APPLICANT If;after making this Certificate of Ex- 0' x- SWIMMING POOL RECEPTOR emption-, you should become subject to the Workers''Compen- CITY TEL. NO. r sation provisions of the labor Code, you must forthwith comp-, LAWN SPRINKLER SYSTEM /I /p `r •� �~• �" ly with such.provisions or this permit shall.be deemed revok- STATE LIC. ed.. WATER HEATER LICENSE NO. © 7 CLASS T C D LICENSED CONTRACTORS DECLARATION DISTRICT NO. SSED.BY I hereby affirm that I am licensed under,provChapter isions of GAS SYSTEM �, OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER S. - 'J and Professions,Code, and my license is infullforce andel ef- 5 PER SYSTEM FINAL' V LIDATION ct. License Number 7 40�/� Lic. Class FI DAT o r FI V Contractor'/'' Date f d le Ao 8.623A ❑ i.am exempt under Sec. 016 '0 O 0.5 B.'&P.C. for this reason ► g Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ ( a -1 6.50 Signature• f TOTAL FEE SINGLE FAMILY., -HOME OWNER-BUILDER DECLARATION Plan check applicante o 0 1 (� 5 0. I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and ( 2 1 7 87 Professions Code): Address.* I„as owner of the property, will do the work and the City Tel. No. structure isnot 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 p , above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, cind_hereby authorize representatives of this County to enter upon the above nti ed property;fo spection purposes. f�? 4` 7 SEE REVERSE FOR.EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT •I hereb 20-0026 DPW 4/87 y,'.affirm that I have a certificate of consent to self in- 76A667A Sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) certified copy thereof (Sec. 3800,Lob. 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 inspection ADDRESS a . department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET(TOILET) Date Applicant /- NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER / Q OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY Iq ADDRESS IF-4rt I certify that in the performance.of the work for which this per- SINK mit is issued, I shall not employ any person'in any manner so CITY TEL. NO. as to become subject to the Workers' Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE,TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption;you should become subject to the'Workers'Compen- CITY TEL. NO. cation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. Fc. WATER HEATER LICENSE NO. CLAS LICENSED CONTRACTORS DECLARATION DISTRICT NO. P BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS S7. 06 9(commencing with Section'7000)of Division 3 of the'Business "OUTLETS OVER fe d Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VAL DATION License Number Lic..Class 0. DATE / ' —d� 0 FINAL 7 U Contractor Date BY �`"` O 0 1 am exempt under Sec. LU B.BP.C.'for this reason ► Plan check fee � Date: PLUMBING PERMIT ISSUING FEE$ SrQ Signature - ' TOTAL FEE 0 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name t Law for the following reason (Section 7031.5, Business and Professions Code): Address 7. H/1, as owner of the property, will do the work and the City Tel. No. structure,is not intended or offered for sale(Section 7044, W: Business and Professions Code). CONSTRUCTION LENDING AGENCY jTAL 65-. 00 I hereby affirm that there is a construction lending agency for t.• Ct•a __, _i the performance of the work for which this permit is issued aas .� (Sec. 3097, CIV. C.). +•HAINc3ty Lender's Name Lender's Address _ I certify that I have read this application and state that the 1 i_t 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 f pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o Permittee Date