HomeMy Public PortalAbout4934 ARDSLEY DR_Plumbing__ 76A667-CE#817 6-66
APPLICATION FOR PLUMBZG PERM-liv,
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING //
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS eV
i-i VIf-
COLEMAN W. JENKINS. SUPT. OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST �_ /e `�
CROSS ST. cr
NUMBER FIXTURE OR ITEM EACH FEE
WATER CLOSET $1.25 OWNER /
BATH TUB 1.25 ADDRE�SS-� ��`d$/e '
SHOWER 1.25 cl ogle TEL. NS.
LAVATORY 1,25 CONTRACTOR
SINK 1.25 ADDRESS Sa e
DISHWASHER 1.25 CITY TEL. NO. S
LAUNDRY TUB 1.25 STATE LIC
LICENSE NO. CLASS
CLOTHES WASHER 1.25 DISTRICT NO GRO ZONE PR C S Y
WATER HEATER 1.50
GAS SYSTEM OUTLETS 1.50 INDUSTRIAL O
WASTE APPROVAL
OUTLETS OVER 5 PER SYSTEM .30 INSPECTION RECORD V
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APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT $ 2 00 UNDER SLAB WORK
ROUGH PLUMBING - - (,
TOTAL FEE .7 GAS PIPING
0
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER
PLUMBING.
I 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 I AM THE LEGAL OWNER OF,AND INTEND TO
RESIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. UTILITY CO. NOTIFIED
SIGNATURE
OF PERMITTEE - FINAL
VALIDATION
M.
CK. O. CASH
1.-rti,a
o .�u�29 5 0 3.25~
WORKER'S COMPENSATION DECLARATION 76A6 26 DPW 9/89 APPLICATION F®R PLUMBING
PERMIT (
I hereby affirm that I have a certificate of consent to self insure, A , ,�u �1 tl��
ora certificate of Worker's Compensation Insurance, or a certified
copy thereof(Pec.3800 Lab: C.) -- - - - -
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS'DIV-
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
department. - NUMBER - FIXTURE.OR.ITEM Q _ FEE LOCALITY" - - :
Date ApplicantWATER'CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
BATH TUB -
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the
SHOWER MAP BOOK PAGE PARCEL,: 1
permit is for one hundred dollars($100)or less.) OWNE -
1 certify that in the performance of the work for which this permit - LAVATORY is issued, I shall.not employ any person in any manner so as to SINK, MAIL
become subject to the Workers'Compensation Laws. ADDRESS &Jt)
DISWASHER CITY-. T i ,TEL.NO. 1
- t
Date Applicant CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT: If, after making this Certificate of _ -&
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO. >'
I hereby affirm-that I am licensed under provisions of Chapter 9` WATER HEATER
(commencing with Section 7000) of Division 3 of the Business and STATE LIC. O
Professions Code,and my license is in full force and.effect. GAS SYSTEM OUTLETS' LICENSE NO. CLASS ` U
OUTLETS OVER / DISTRICT NO. PROCESSED BY o
5 PER SYSTEM o
License Number Lic.Class V
FINAL t y VALIDATION W
/ DATE W
Contractor DateU)
FINAL - Z
I am exempt under Sea BY
B.&P.C:for this reason
Plan check fee
% Date: y
PLUMBING PERMIT ISSUING FEE$ 7
Signature a __
TOTAL FEE
❑
SINGLE FAMILY Plan check applicant '• - - t�•i"s�a_-C% �,�-_ ._
HOMEOWNER-BUILDER'DECLARATION Name
I hereby affirm that I am.exempt from the Contractor's License Laws
for the following 'reason (Section 7031.5, Business,and Professions. Address
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 4 •• t _
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.)
t
Lender's Name
Lender's Address
I certify that I have read this application and state that the above - y
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 or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Wirnittee Date