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1r- D"17a11-90 APPLICATION FOR PE N=
ARTicaT OF BUILDING AND SAFE7Y
TY ,
COUNOF LOS ANGELES PLUMBING 1
WILLIAM J. FOX, OHI[F [NGIN[ER
DIEITRIMT NO. GROUP ZONE PERMIT NO.
FOR APPLICANT TO FILL IN
rLLMR[RA—W REll"
LVED MY READY FOR DA I VIED
FIRXT INXPEOTION
ADDR11X � / „„11-�
%U 19
ING
aMY � TIL No. %U 19 X
ODUNTY ir LouA RyLICENSE NO. IRKS
t7�o
H EAR ENT p
P Ure.n F7= 011100111 ST. I
NUMUM TYri of r1XTU Rt OIC ITER FII QWNrR a
MAIL
WATICR OLOX[T(TOILM 0 0.60 11 ADDRFM A d
RATH TUB ! 0.60 o1TY TEL No.
SHOWER CLOD 1 HICRJCIfY ACKNOVnIDMIC THAT I HAVE READ THIS
LAVATORY (WASH MAXIH) 0.6O AND
AND MTATI THAT TH[ OO
AXVE 1■ OORR[ T
AND AGREE TO COMPLY WITH ALL OOLNTY ORDINANDEX
KITOHEN MINK 0.60 AND NATE LAWN R[XUL.ATING PLUMMING.
I DERTIFY THAT 1 100� THE AXOVE VALID LOR
LAIJMDRY TUM OR TRAY Q CLOD AXOKL[R DOUNTY LJO [. 'RJ,AM TH[ A EMA W
ONFA
OF I
THE RXID[NTIAL IXORI�[D OYL
MAX XYSTE LrrL[TO 0.6D
X1 X NATU RI Or
WATER HEATER CLOD rERMr
■LOP MINK 0.6o INSPECTION RECORD
Mom MINK ! CLW _
FLOOR DRAIN 0 0.60 N s10R� Lr+B
DIMHWAIHER 0 0.60
DRINKING FOUNTAIN 0 CL60
URINAL 0.60 -t [s r 'C I
HOUSE NEW” CLOG _
MIMO[LLAN[DUX
O
APPROVALS
DATE INWPM133TU1f'■ MAAt[
ROUGH PLUMMIN■
a" PIPING 3 ^ �
GAM VENT
13 K=W D D L 1.'00 D[X10-OO L
XETTIO T ■rPTID TANK
DRAIN ( PIT ( I 1.D0 III
PERMIT 1.00 EF.3
-EN OTIFIED
TOTAL FEE 5
r
WORICERS'C°MPE"SAT'°" DECIARATION 20-0026 DPW 4197 APPLICATION FOR PLUMBING PERMIT
'IrOeeby,��rm that I have a certificate of consent to self In- -7Mb67A
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(RFV, 8/B6)
cer:Hfled copy thereof (Sec. 3800,lob. C.)
Polley No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certtfled copy Is hereby furnished. BUILgING
FOR APMJCANT TO FILL IN(PRINT OR TYPE) EL UE
I—I Certified copy Is filed with the county building Inspection ADDRESS j�y� � /Q
I -I department. NUMBER FIXTURE OR ITEM _ FEE LTM
Dote• �App lrcant WATER CLOSET(TOILET) J4O NEAREST h /' /
CtRTIFICATE OF EXEMPTION FROMWORKERS' BATH TUB d SG
SS ST- /7�� l . ^10 0z/V
COMPENSATION INSURANCE OWNER P� R' sZ �jC�
(This section need not b.6 compliW If the word Invlolved by SHOWER MAIL1�1
thi'permlf Is for one hundriDd dollars ($100)or law.) LAVATORY ADDRESS��Y�
I certtfy that In the per-formance of the work for which this pef-
m1t is-Issued, I shpH rs
-not employ any peon In any maoner so SINK
M s Yo become subject to the Workers' rnpensa aws. t
D&-WASHER CONTRACTOR
Dote Applicant L CLOTHES WASHER
L ADDRESS
NOTICE TO APPLICANTr If, after making this Certificate of Ex-
emption;you shduld become subject to tha Work6n'Comperl- SING POOL RfCFCOR
od CITY TEL NO.
cation Provisions of iHn Labor C e, you must forthwLth comp LAWN SPRINKLER SYSTEM
ly with_avch proVlslonu or this permit sha(I be-deemed revok- STATE 11C.
e<�• . .. WATER HEATER LICENSE NO. CLASS
4ICENSED CONTRACTORS DECLARATION bIST NO. SSED BY
I here-by affirm that I am licensed under provisions of Chapter GAS SYSTEM j OUII_ETS
9(cdmmehcing with S6ctron 7000)of Division 3 of the Business O L/
f
and proferslons Code, and my license is in full force and of- 5PER SYSIEM FINAL VA�IDATIO
• DAA (L
Llcenae Number 11c. Class T V
FI �
Contractor
DO to BY O
_. )
],am 6xempt.underSe6. W
B.BP.C, for this reason Plan check fee ,
Date' PLUMBING PERMIT ISSUING FEE$
Slgnaturq_ f� b
TOTAL FEE
SINGLE FAMILY Plan check applicant o 0 0 2µ5 i9
DOME OWNER BUILDER DECLARATION. pP
1 hereby affirm that I arp exempt from the Contractors License ryamg12 9 $8
La03
Law for the following reason•(Sectlon 7 ].5, Business and
�rofeulons•Code): Addreas43¢2 , .9,4R?Md ff.
Q I, as owner of the property, w1Jl do the work and the QtyT Ter. N _
structure is not lotehddd or offered for sale(Section 7044;
Business and}Professions Codn).
t. CONSTRUCTIOhI LENDING AGENCY
I hereby off lrm thgt there is a construction lending ogency.for
the Performance of the work fpr which this permrf Is Issued -
(,Sec. 3097, Civ.C.).
Lend6r.s Name
Lender's Address
I certify. that I have read this application and state that'the ►
above Informatlon•Is 4orreGt. I agree to comply with all County 1
ordinances and$tate laws regulat(ng Plumbing, and hereby
authorize representatives of this County to enter upon the
abov entlon o rty for rnapectfon purposes.
SEE REVERSE FOR'EXPLANATORY LANGUAGE
Signature of Permittee !!� Date
I •
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