HomeMy Public PortalAbout6212 AVON AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 26DPW 9/89 APPLICATION FOR PLUMBING PERMIT
76A6
I hereby affirm that I have a certificate of consent to self insure, 76A667A
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec. 3800 Lab. C_) !
�J _ COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No. ( Company
Certified copy is hereby furnished. ADDRESS
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection
department. v /� / /'/ NUMBER FIXTURE OR ITEM @ FEE
Date 7^� ' C y Applicant l aJ �' �✓"�� LOCALITY
WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the SHOWER MA'.0 OK PAGE PARCEL}/
permit is for one hundred dollars($100)or less.) LAVATORY OWNER �yy/
1 certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as toMAIL
SINK ADDRESS /T
become subject to the Workers'Compensation Laws.
DISWASHER CITY TEL.NO.
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR
Exemption, you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS arko
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION ! CITY TEL.NO. Y
WATER HEATER o/ 0.
I hereby affirm that I am licensed under provisions of Chapter 9 /� c
STATE 0
(commencing with Section 7000) of Division 3 of the Business and LICENSE NO. a�� CLASS
Professions Code,and my license is in full force and effect. I GAS SYSTEM Z OUTLETS
OUTLETS OVER DISTRICT NO.D� PROCESSED BY
��77
License Numb �er�� SZ 5 PER SYSTEM
Lic.Class! / /Z
I fir/ FINAL R
DATE N-ALIDATION - W
Contractor " Glos , Date 7� y V �s3._ 1 .7
ElI am exempt under Sec. BY AL _ a•
B.&P.C.for this reason e I:La
Date:
Plan check fee , _
Signature PLUMBING PERMIT ISSUING FEE$ Z I j' I 'x
❑ TOTAL FEE `IE".
SINGLE FAMILY Plan check applicant I +t•=E °?
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 Professions Address I IU tij,l_(Y
Code): }- _
El 1,
Tel. No. �, _ `il s --
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-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
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DEPARTMENT OF BUILDING AND SAFETY A.T'PLICATION FOR PERMIT
a --
LDL' "I' tar LOS 'UN:GiLES PUL)TINIBlitiv
"IQ- .�liTI—FRE. OF 1NST i.I.�,ATION I DISTR:C T No. ` a t ur ! No4H J
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WED --_--- _ HIZATIR, ( C¢'J9f'OCYL '6"iZY41t:TAM P,EA7Y FCR c f
—� FI4ST iNSPECTICN I 'Y4� 1 r�
„ y aAS I I MISCELLANEOUS
Cs APPLICANT FILL IN IIF.AVILY OUTLINED PORTION ONLY
JOB
_ NAME-J':_�_.') ......f�ti. �i_./..f��� �•. .. .+L.9J.t•.�..�f �. :ADDRESS
LOCALITY
NEAREST
J 1 C!TY t
).._. r!/^ . ]• TL. NO. l L!1 CROSS 8T. .--�
' /TATE �•� COUNTY
LICP•NIIC NO.�;�„1 R[O. NO_ C
LOCATION OF SEPTIC TANK. OR CESSPOOIA Z MAIL
ADDRESS
NORTH 0
I I I r •-CITY TEL NO-
i I CORREUrIONS
J. i
OOUTH_.
j:. 12140WER APPROVALS
DATE INw►1tTp w'• M.Nt
_______LAVATORY AVATORY ___-REFRIGERATOR: J
ROUGH PLUMBING r
KITCHEN SINK —_WATER SOFYAN[R J --
GAS PIPINQ�
rl COR SINK AND TRAP
.1 .' - - .. 'OAS VENT..
-- _
LOP SINK ..__—+..J'LOOR DRAIN ;
.. CESSPOOLTRAY
} SEPTIC TANK.
WATER CLCSET __ DRINKING FOUNTAIN I.
SEWLIR
F c
--WATER HEATER _ DENTAL LAVATORT
UTILITY CO. NOTIFIED I
OUTL .--..._.._w�OA FOUNTAIN
^, -��
FINAL I�T—Z_411_4yI }';,•'-r�F',�.i )• "`'.;I
THE LEQAL OWNER OF THi ABOVE LOB ANrS[LE6
COUNTY REQISTRATIOti NUMBER. r _�
TOTAL NUMa[N OF MIKTURi%_ I "'" -""n'� i+�-r •/...%�i7 i i,its :il'•?;.w
�O[PTiC TANK _ } _ -
'- 1 AM THE LEGAL OWNER OF THEE PROPERTY D[SCIRIREDPOOL
Ear ABOVE.
: ;
i s s 7
TOTAL FEc 4 # f_
r: �.i :r .,rad: '�'. � �'4� -w..'.»u.,r.-��-LM.r;• ,.;,-v,�'�Q x r .f 5 �'"f'l '4?-t+,.'
.•.. ... � ,._ ,Adz �.,.�.
r
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11115
DEPARTMENT OF BUILDING AND SAFETY ' , APPLICATION FOR IOPFU:IT 7
COUNTY OF LOS ANGELES PL UPAPL TNG
NATURE OF INSTALLATION DISTRICT NO. I GRORJP I rto. I PERIWl NO.
ROUGH :�
_
7�u� PLU RING ,FIXTURE♦ _ '
i COMPLETE � .C� r /:' I � f
HEwTrR CESSPOOL I '4EPT!^TANK _ READY FCR I RrCF Y DnY
y FIRST INSPECTION i v, �� _� i i LATE W O-JED J
GAS /\I ®ri
MISCELLANEOUS ��" I �I r�-f,/rRe
APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY - .E- ;, t o
amm
2 -_.-- r ♦ v A.^.-KESS
LOCALITY
IL CITY TEL.NO 7if> NEAREST _
CROSS ST.
A—Idio
STATE COVNTY _
LICENSE NO. REG. NO. K NAME
It
LOCATION OF SEPTIC TANK, OR CESS p z MAILw 3: - - --
_ADDRESS
NORTH_ O
CITY
•� TEL.NO.
CORRFf T'rnNc I t t
7_1 `�rr
3I I>
N
BESCRIPTIoiv aF
t.,. .:-+..• o!:a. a�i1:14:':.+..nL:�..r r.:.c�7s'; rsa k:}iG.:..na,Z,-�iir' - - sN:'+-zr�W ♦ _ -
.� +tit.E
_ -_-3HOwER .APPROViA,
_DISWWASHER
--/- LAVATORY REFRIGERATOR r DATE WNO►[CTQR-- Are
V.
-`� --j-KITCHEN SINK ROUGH PLVMBING.-• l f :,'�
.}�• WATER SOFTENER
SINK GAS PIPING.-----.FLOOR
SAND TRAP
G. ----SLOP SINK GAS YE'NT
-// _— FLOOR DRAIN
—=-1-_.WASH TRAY --
'�l' - URINAL
- _ SEPTIC TANK
WATER CLOSET
DRINKING FOUNTAIN
--I-WATER HEATER W ER
DENTAL LAVATORY!,'
V. '—/-METER-.J'�'-n.��.gR -SODA F-OUNTAIN �
UTILITY CO.NOTIFIED I[� I
_ _ "�"TT----- ,isms
r, -
[E.111A
M THE LEGAL OWNER OF 7 .ret ra
.__ COUNTY REGISTRAT ON NUMB,E?, ABOVE LOB /!N__- `
T^T?,L YU.:!9E;2 CF €IKTU:.aS-� (/"' - J__
SEPTIC TANK
,,?2
PLUMBER
1 AM THE LEGAL OWNER OF THE FRO ��Ty DEBCifilel£D r
t.y CESSPOOLS
G.• _
ABOVE.-
-PERMIT FEE -
-TOTAL FEE
OWNER t