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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESSG / YU
JOHN A LAMBIE COUNTY ENGINEER 16
WILLIAM A JENSEN SUP T OF BUILDING TY
FOR APPLICANT TO FILL IN TOSS d �y- O i✓
NUMBER FIXTURE OR ITEM EACH FEE
OWNER
WATER CLOSET
$l 25 � MAIL
BATH TUB 125
ADDRESS
SHOWER 125 �� CITY TEL NO
LAVATORY 1 25S V CONTRACTOR
SINK 125S ADDRESS �/� 0.4a vE
DISHWASHER 125 12- CITY �� tD/� TEL NO -30$]E]STATE El
LAUNDRY PUB 1 25 ` REGISTRATION CONTRACTOR NO ♦ a� COUNTY
CLOTHES WASHER 1 25 S DISTRIC O GROUP ZONE P OC ED BY
WATER HEATER 1 50 "j) T__ RA
GAS SYSTEM OUTLETS 1 50 s"Q INDUSTRIAL
WASTE APPROVAL
OUTLETS OVER 5 PER SYSTEM 90 INSPECTION RECORD d
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APPROVA S DATE INS ECTOR 5 SIGNATURE
PERMIT 5 2 00 UNDER A'B'WORK
ROUGH PLUMBING
TOTAL FEE GAS PIPING
1 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
PLUMBING HOT WATER HEATER a •
I HEREBY CERTIFY THAT I 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 t
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY UTILITY CO NOTIFIED
SIGNATURE ^ /
OF PERM ITTE FINAL
od-
,,-V�ALIDATION ROBERT A WOOD
cK M J CASH SUPERVISING MECHANICAL ENG R
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WORKERS COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A �)
insure or a certificate of Workers Compensation Insurance CE 817(REV 10/81)
or a certified copy thereof (Sec 3800 ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnishe
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �1 S _
Certified copy is filed with the county builds i spec ADDRESS p` I
ti n d rtment NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant 1, WATER CLOSET NEAREST '
CERTIFICATE OF EXEMPTION OM WORKERS BATH TUB CROSS S7
COMPENSATION INSURANCE SHOWER OWNER ell
(This section need not be completed if the work involved by MAIL
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 CITY TEL NO
so 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 SWIMMING POOL RECEPTOR t r
Exemption you should become subject to the Workers PSTAT1 .01
TEL NO�y�7�
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be LIC G 7'
deemed revoked WATER HEATER CLASSLICENSED CONTRACTORS DECLARATION NO PRO SSED BY
I hereby affirm that I am licensed under provisions of Chapter 9GAS SYSTEM OUTLETS(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 0�� �? VALIDATION V
License Number n ' Lic Class Qt
FINAL 0
Contractor Date BY V
116!I
I am exempt under Sec
N
B&P C for this reason �
Plan check fee
Date Poo-
PLUMBING PERMIT ISSUING
Signature
EE
Plan check applicant f
SINGLE FAMILY ,
HOME OWNER BUILDER DECLARATION Name b 7 5 4 A
I hereby affirm that I am exempt from the Contractor s License Address ►
Law for the following reason (Section 7031 5 Business and # 0 0 0 0 0 5
Professions Code) City Tel No
❑ I as owner of the property will do the work and the 210.0 1 6,5 0
structure is not intended or offered for sale (Section
7044 Business and Professions Code) , 0 to 0 1 6.5 0=
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CONSTRUCTION LENDING AGENCY 0'08-82
1 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 law plating Plumbing and hereby
auth4menned
ntativ of is County to enter upon the
abovpro rty for spection purposeSEE REVERSE FOR EXPLANATORY LANGUAGE
Signtee ate
r
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 0808250015
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285 0488 EXT
LEGAL ID FEES PAID BUILDING ADDRESS
ITR 5903 LT 30 BL 001 UN 002 6255 AVON AV 1
I IEEE DESCRIPTION QUANTITY UOM AMOUNT SGAB CA 917752649
(ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET LONGDEN
15386 006 031 101 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 596 GRID G2 LOCALITY TEMPLE CITY Cl
I 125 LAVATORIES/SINKS 3 00 FIX 48 60 1 I
TENANT 145 WATER CLOSET/URINAL 2 00 FIX 32 40 ITSSUED ON PROCESSED BY PLAN BY EXPIRES ON
TOTAL FEES 108 75 108/25/08 SR 02/21/09
OWNER TEL NO IFINALTE+ FINAL BY CODE
IHUANG ZHI YONG (626) 905 5583 I 1 ,(�/ 1
16255 AVON AV `v o 1
SGAB 917752649 { ID RIP ION OF WORK
I PLUMBING FOR KITCHEN AND BATHROOMS REMODEL
1APPLICANT TEL NO I
IHUANG (626) 905 5583
16255 AVON AVE ISPECTAL CONDITIONS I
TEMPLE CITY CA 91780
ICONTRACTOR TEL NO I (APPROVALS DATE INSPECTOR SIGNATURE
IZHIYONG HUANG (626) 905 5583 1 1 1
18914 GREENWOOD AVENUE LIC NO 1UNDER SLAB WORK
ISAN GABRIEL CA 91775 1247 NONE
I IWATER SERVICE
I (PLASTIC Y/N METAL Y/N 1
(ARCHITECT OR ENGINEER TEL NO I I I
IKENT C K WU (626) 966 4975 IROUGH PLUMBING
�R
11274 E CENTER COURT DR #211 LIC NO 1 I I 1 riOISA��.. I
ICOVINA CA 91724 NONE IGAS PIPING
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I IREPORT ID DPR263 ROUTE TO BS0508 1 1 1 I
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