HomeMy Public PortalAbout9217 BLACKLEY ST_Plumbing__ APPLICATION FOR PLUMBING PERMIT 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /
ADDRESS L Lt
JOHN A. LAMBIE, COUNTY ENGINEER
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM
OWNER
WATER CLOSET MAIL
BATHTUB ADDRESS
SHOWER CITY TEL.NO.
LAVATORY CONTRACTO
SINK ADDRESS
zi
DISHWASHER CITY ` / TEL.NO
j ��++ Q
LAUNDRY TUB STATE
REGISTRATIO O. ` 95 ! G-7'COUNTY ❑
CLOTHES WASHER
DISTRICT. GROUP ZONE READY FOR INSPECTION
WATER HEATER l4i
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL
INSPECTION RECORD
177
APPROVALS
Ca $1.00 PER ITEM DATE INSPECTOR'S SIGNATURE
OR FIXTURE $ UNDER SLAB WORK
PERMIT $ 1100
ROUGH PLUMBING
GAS PIPING
TOTAL FEE �
GAS VENT
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION HOT WATER HEATER
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING FIXTURES ,f
li PLUMBING.
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR GAS TEST
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE UTILITY CO. NOTIFIED
DESCRIBED RESIDENTI L PROPERT '.
SIGNATURE
OF PERMITTEE FINAL
ROBERT A. WOOD.
VALIDATION
SUPERVISING MECHANICAL ENG'R
CK.: M. 0. CASH
F ` iso 5 3 4 9 R' SEP 3 0 5 A 2.0 0vi
WORKERS'COMPENSATION DECLARATION
20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
4.hereby, affirm that I have a certificate of consent to self in- 76A667A
sure,.or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
certified copy thereof (Sec. 3800, Lab. C.)
P&cr No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
' •
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS 9212 BLACKLEY
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY TEAZPLE CITY
Y
2, WATER CLOSET(TOILET)
Date Applicant CROSS ST.r. ENCINITA AVE
CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BATH TUB
COMPENSATION INSURANCE SHOWER OWNER TAH FANG HSIN
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) 2 LAVATORY D ADDRESS SAME ABOVV
I certify that i,n the performance of the work for which this per- SINK CITY T�. �28520 7
mit is issued, I shall not employ any person in any manner so
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS �-
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER, LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
Thereby affirm that I am licensed under provisions of Chapter 1 GAS SYSTEM OUTLETS
9,(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL // VALIDATION
feet. DATE t '�Z. � ��/ O
License Number Lic. Class 0
FINAL
Contractor Date BY ` O
b—
I am exempt under Sec. LU
B.&P.C. for this reason 7 Plan check fee Poo.Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE 'U
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby-affirm that I am exempt from the Contractor's License Name -
Law for the following reason (Section 7031.5, Business and
Professions Code): Address
IXI Cit Tel. No. �`l� r_+� 1'
4� I, as owner of the property, will do the work and the Y •:i•__r
structure is not intended or offered for sale Section 7044, 1 ITEMSi
Business and Professions Code). 9
pool
5y 50
CONSTRUCTION LENDING AGENCY
951
1 hereby affirm that there is a construction lending agency for =_. 1 ;. , i 5.-z11
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). [C;JANET .0,D
Lender's Name
,- 0000 F—•1AU1,t +v�.}.s_'i i
Lender's Address g _ }
I certify that I have read this application and state that the
i tla i 13t
above information is correct. I agree to comply with all County ,
ordinances and State laws regulating Plumbing,'and hereby
author'ze re resentatives of is County to enter upon the
ab ' -ment on. �operty f nspection urpos s.
— j — l SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date