HomeMy Public PortalAbout5453 BALDWIN AVE_Plumbing__ 7EA6E7 17 a-so '® APPLICATION FOR PERMIT
DEPARTMENT OF BUILDING AND SAFETY
COUNTY OF LOS ANGELES PLUMBING 1
WILLIAM J. FOX, CHIEF ENGINEER
FOR APPLICANT TO FILL 1N DISTRICT NO. GROUP ZONE PERMIT NO.
PLUMBER LLEY BOULEVARD MOW CO, -2> �� � �
RECEIVED BY READY FOR DATE ISSUED
M 1 FIRST INSPECTION
ADDRESS8300 EAST VALLEY BLVD. Ir °'�
BUILDING
CITY ROSEMEAD AT. 2'2719 ADDRESS .�3COUNTY
Q I�, TEL. NO.c ggry�y /'
LICENSE NO. 93N1 6-30- '� LOCALITY 7 6:
EXPIRES
NEAREST p
PERMIT FEES cRoss sT.
NUMBER TYPE OF FIXTURE OR ITEM FEE OWNER
MAIL
WATER CLOSET (TOILET) @ 0.50 $ ADDRESS
/I I BATH TUB @ 0.501 CITY TEL. NO.
T
SHOWER ' @ 0.501 1HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS
LAVATORY (WASH BASIN) @ 0.50 I APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND
AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND
�I KITCHEN SINK @ 0.50 STATE LAWS REGULATING PLUMBING.
I CERTIFY THAT 1 POSSESS THE ABOVE VALID LOS
LAUNDRY TUB OR TRAY @ O.50ANGELES COUNTY LICENS OR I AM THE LEGAL OWNER
OF THE RESIDENTIAL PRC ERTY DESCRIBED ABOVE.
GAS SYSTEM-OUTLETS @ 0.50 I
�
SIGNATURE
EF WATER HEATER @ 0.5.0 I
SLOP SINK @ 0.50 I1 INSPECTION RECORD
�J FLOOR SINK @ 0.50
FLOOR DRAIN @ 0.50
DISHWASHER @ 0.501
DRINKING FOUNTAIN @ 0.50 I
URINAL @. 0.501� J
HOUSESEWER @ 0.50I I Q
MISCELLANEOUS I 0
l O
I
APPROVALS
DATE INS.PECTOR•S NAME
ROUGH PLUMBING / 1
GAS PIPING
-Al
I GAS VENT L i
l CESSPOOL @ 1.00 CESSPOOL
I_SEPTIC TANK: I SEPTIC TANK /
I DRAIN ( ) PIT ( ) @ 1.00 -- SEWER IT
PERMIT . 1.00 GAS TEST
UTILITY CO. NOTIFIED
TOTAL FEE
� FINAL � � J
WORKERS'COMPENSATION DECLARATION- APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or'a 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) ADDRESS �w-2,
w> �
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant WATER CLOSET 2 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB y CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER so D
(This section need not be completed if the work involved by yt
the permit is for one hundred dollars $100 or less. MAIL
P ( ) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINKCITY J� TEL. NO. J
so as,to become subject to the Workers'Compensation Laws. DISHWASHER </
CONTRACTOR o
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of - yt s-t7 j
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL.
P P Y LAWN SPRINKLER SYSTEM e I
with comply with such provisions or this permit shall be STATE �j ' LIC.
deemed revoked. WATER HEATER LICENSE NO. J / LASS
LICENSED CONTRACTORS DECLARATION DISTgIck O ESSED B
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS y U
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL V DATION
,
License Number Lic. Class DATE ®;_ �.
FINAL
Contractor Date BY
2" 0,
❑ I am exempt under Sec. �J
Ltl'
B.&P.C. for this reason Plan check fee �
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
y
SINGLE FAMILY Plan check applicant _
HOME OWNER-BUILDER DECLARATION Name ill)€ 1 aY
I hereby affirm that I am exempt from the Contractor's License Address 3307 icyl_I
Law for the following reason (Section 7031.5, Business and
Pr ssions Code): City Tel. No. i 1 TENS;
I, as owner of the property, will do the work and the TOTAL
structure is not intended or offered for sale (Section 95 .50
7044, Business and Professions Code). CHEECK 95.50
CONSTRUCTION LENDING AGENCY (I�l
I hereby affirm that there is a construction lending agency for CHANGE .00
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
13000—E sl1131 4/ 9/90
Lender's Name 9992 1 AN 8:
21
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 C unty to enter upon the
above-mentioned property for i ction purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
>91T.ture of Pe ittee Date