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Home My Public Portal About9210 BLACKLEY ST_Plumbing__ 76AS67C (CE-817B) -9/75 APPLICATION FOR PLUMBING PERMIT BUILDING AND SAFETY DIVISION FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING �� G NUMBER FIXTURE OR ITEM @ FEE ADDRESS WATER CLOSET LOCALITY BATH TUB NEAREST CROSS ST SHOWER OWNER LAVATORY MAIL (� ADDRESS S' SINK CITY TEL NO DISHWASHER _ CONTRACTOR � / J ex ,CLOTHES WASHER ADDRESS c SWIMMING POOL RECEPTOR CITY STATE LIC TEL NO LAWN SPRINKLER SYSTEM WATER HEATER '� LICENSE NO f'- CLASS DISTRICT NO GROUPZONE OCEVGAS SYSTEM OUTLETS -7OUTLETS OVER SJl�JCD 5 PER SYSTEM INDUSTRIAL w WASTE APPROVAL � INSPECTION RECORD Z Plan check fee PLUMBING PERMIT ISSUING FEE S TOTAL FEE Plan check applicant ��— Name APPROVALS DATE INSPECTOR 9 SIGNATURE UNDER SLAB WORK ��®.•�� Address ROUGH PLUMBING City Tel NO GAS PIPING IHEREBY 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 HOT WATER HEATER PLUMBING I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES �) LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST AO S��Jir CALIFORNIA OR THATI THE LEGAL OWNER OF, AND INTEND TO RESIDE IN THE ABOVE D RIBED RESIDENTIAL PROP Y UTILITY CO NOTIFIED SIGNATU RE OF PERMITTE FINAL iZ -77 r PLAN CHEC V (DATION CK M Q CASH PERMIT VALIDATION M 0 CASH r 4 5 7fiA66&(.CE-8117f�74/72 �C2 APPLICATION �rgR PLBING PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING MAKE CHECKS PAYABLE TO ADDRESS 210 Blackie HARVEY T. BRANDT, COUNTY ENGINEER LOCALITY Temple Cit FOR APPLICANT TO FILL IN (PRINT OR TYPE( NEAREST CROSS ST NUMBER FIXTURE OR ITEM @ FEE WATER CLOSET 1 75 OWNER de Construction Coe Ince MAIL BATH TUB 1 75 ADDRESS 20 Birchcroft SHOWER 1 75 CITY Arcadia TEL NO LAVATORY 1 75 CONTRACTOR Owen Bros. Plumbing Ince SINK 1 75 ADDRESS 4265 No. Baldwin Ave. _ DISHWASHER- _r — _ --1 75 —CITY-- El MontB"' TEL-NO 443_0079 CLOTHES WASHER 1 75 STATE LICENSE NO 231 741 CILASS C36-2o SWIMMING POOL RECEPTOR 1 75 DISTRICT NO GROUP NE F CESSE BY LAWN SPRINKLER SYSTEM 1 75 a _ WATER HEATER _ 1 75 INDUSTRIAL WASTE APPROVAL a GAS SYSTEM OUTLETS 1 75 I SPECTION RK RD V OUTLETS OVER 5 PER SYSTEM 30 O 1-- C� W O.. Plan check fee See Reverse PLUMBING PERMIT ISSUING FEE $ 3 00 TOTAL FEE APPROVALS DAT ,SPECTO SIGNATURE Plan check applicant UNDER SLAB WORK 10 1171-6, Name ROUGH PLUMBING Address GAS PIPING City Tel No GAS VENT Z _ 7 I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION HOT WATER HEATER _ AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES r WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING I' w PLUMBING _ GAS TEST _ IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO NOTIFIED LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF C CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO LRESIELI E ABOVE D R RESIDENTIA ROPERTY FINAL 74, ITTEE PERMIT VALIDATION cK M o CASH PLAN CHECK VALIDATION CK M 0 CASH 3731 OCT 16 5 0 2 2.2 5 L WoCOMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hQreV-p affirmrm that I have a certificate of consent to self 76A667A - !f'insurelor a certificate of Workers' Compensation Insurance, CE 817(REV 10/811 01 a,c�;;if^e��,-bi Jerry ( i,900, L b� ) J` COUNTY OF LOS ANGELES BUILDING AND SAFETY P❑o icy o f �—Company- . 4 ' Certified copy is hereby furnished BUILDING ® Certified copy is file with the ou t building inspec- FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS (� tion department — f1C-tJ k C��D NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET Date 1, i Applicant NEAREST \ c _ CERTIFICATE OF EXEMPTION FROM ORKERS' BATH TUB CROSS ST COMPENSATION INSURANCE SHOWER OWNER (This section need'not be completed if the work involved by MAIL �,rj the permit is for one hundred dollars ($100)or less) LAVATORY ADDRESS C i I certify that in the performance of the work for which this v permit is issued, I shall not employ any person in any manner SINK CITYfie TEL NO so as to become subject to the Workers Compensation Laws DISHWASHER 1 1 �� CONTRACTOR r Date Applicant CLOTHES WASHER ADDRESS [�_ ` NOTICE TO APPLICANT If, after making this Certificate of (�-i SWIMMING POOL RECEPTOR d a( Exemption, you should become subject to the Workers' q( . ---Compensation provisions-of the-Labor-Code,-you'must forth.:—"" - --- " �_ _ CITY � I( TEL-NO � with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE - LIC � f deemed revoked I WATER HEATER LICENSE NO CLASS KJ LICENSED CONTRACTORS DECLARATION DISTRICT N ROCESSED BY ,I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect 5 PER SYSTEM IL FINAL f� DATE V IDATION u 11 0 Ike *Aft License Number °✓ Lic Clas t r FIN O Contractor 1 Date �7 BY ea_ ~ U r-1W I am exempt under Sec �� H B&P C for this reason Z Date Plan check fee Signature PLUMBING PERMIT ISSUING FEE$ TOTAL FEE a ` zi 4 4 A SINGLE FAMILY Plan check applicant # o 0 0 0 0'5 HOME OWNER-BUILDER DECLARATION Name ( o o 3 Q,5 Q I hereby affirm that I am exempt from the Contractor's License Add Law for the following reason (Section 7031 5, Bressusiness and o o 0 3 0.5 0 5 ❑Professions Code) City r Tel No -Q (I,2 9—8 5 I, as owner of the property, will do the work_and the structure is not intended or offered for sale and 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 1) 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�gth ulating Plu bang, and hereby f authorizer esentatives is County ent r upon the above-me ton p rt inspectio urpos s SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee e ' t o