HomeMy Public PortalAbout9113 BLACKLEY ST_Plumbing__ COUNTY OF LOS ANGELES APPLICATION FOR PERMIT
Departme4 of County Engineer
DIVISION OF JUILDING & SAFETY
WILLIAM J XOX, County Engineer
FOR AP IC NT TO FILL IN DISTIRLUT No. GROUP I ZONE .
PLUMBER E'VE BY READY FOR DATE ISSUED
FIRST INSPECTION
ADDRESS
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BUILDING L< .��G� v
CITY TE No —ADDRESS' r ,
COUNTY LOCALITY L
LICENSE NO EXPIRESNEAREST
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CROSS ST. �) .L/Y�/y0
PERMIT FEES /n/ /1 /�/� y� o
NLMBER TY6
PE OF FIXTURE OR ITEM FEE OWNER wSY ye.0 �/7 4.C-
MAIL
WATER CLOSET(TOILET) (� QmSD $ � ADDRE599//fq 2 E— �I L .0 l- 22.02
/
BATHTUB O 50 F✓ CITY TEL NO
SHOWER 050 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS
LAVATORY (WASH BASIN) O 5❑ APPLICATION AND STATE THAT THE ABOVE IS CORRECT
AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
KITCHEN SINK O 50 AND STATE LAWS REGULATING PLUMBING.
1 CERTIFY THAT IPOSSESS THE ABOVE VALID LOS
LAUNDRY TUB OR TRAY @ 050 ANGELES COUNTY LICENSE. OR I AM THE LXGAL OWNER
OF THE RESIDENTIAL PROPERTY D S IB /ABOVE.
GAS SYSTEM_ @ O 50
1 SIGNATURE OF O
WATER HEATER @ O SO PERMITTE / P
SLOP SINK @ 050 INSP� TION RECORD
FLOOR SINK @ O 50
FLOOR DRAIN 050
DISHWASHER @ 050
DRINKING FOUNTAIN ® O 50
URINAL @ 0.50 Q �\
HOUSE SEWER @ 1350 Z
MISCELLANEOUS 2
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/ ) /Yqtr c 0
F
APPROVALS
DATE INSPECT R•9 NAME
ROUGH PLUMBING
' GAS PIPING
GAS VENT
CESSPOOL 1 00
CESSPOOL i
SEPTIC TANK: SEPTIC TANK
DRAIN ( ) PIT ( ) 1 00 SEWER
PERMIT . . . t 00 GAS TEST
UTILITY CO.NOTIFIED
TOTAL FEE
/ _A— I NAL
7GA667 DBS#17 10/52 `
r
% WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby-affirm that I have a certificate of consent to self 6A667A
,insure, ar a certificate of Workers'8��
CE 817(REV 10/81)
or a cecy t• hereof (S� ec 38COUNTY OF LOS ANGELES BUILDING AND SAFETY
P❑olic mpar,
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Iq Certified copy is filed with the c unty building mspe ADDRESS
tion de art en NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET
Date � Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars $100 or less MAIL
P ( � I LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL NO
CVI
so as to become subject to the Workers'Compensation Laws DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL N0�9
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PRQCEED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �(
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �cV �
and Professions Code,an license is in full force an�ffect 5 PER SYSTEM FINAL VALID IONLicense Numb r �� Lic Clas — DATE A/ ��— 6A
O 0
FINAL
Contractor ate BY C
r_1 - 657
I am exempt under 5 c �
B&P C for this reason Plan check fee g
Date PLUMBING PERMIT ISSUING FEE$ ,S6
Signature
TOTAL FEE1161,5 )
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address 2 4 5 4 A
Law for the following reason (Section 7031 5, Business and
Professions Code) City Tel No # 0 0 0 0,0 5
❑ 1, 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 ( o 0 1 650
the performance of the work for which this permit is issued
(Sec 3097, Civ C ) 0 0 0 1 6505
Lender's Name 0 7, 1 5-85
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
ordinanc s and State jaws reg ting Plumbing, and hereby
outhoriz representatives is County to enter upon the
above- entioned pr rty for inspectiop pyrposes
,Zv`,�/\� SEE REVERSE FOR EXPLANATORY LANGUAGE
tow V a
Signature o Permittee 77 Date