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HomeMy Public PortalAbout9468 BLACKLEY ST_Plumbing__ 76A667A ICE H 1 71B1- 1 1/76 CL'44�t a APPLICATION FOR PLUMBING PERMIT BUILDING AND SAFETY DIVISION FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING NUMBER FIXTURE OR ITEM FEE ADDRESS WATER CLOSET LOCALITY NEAREST / r BATH TUB CROSS ST. � SHOWER OWNER 4 D LAVATORY MAIL G ADDRESS9�6 '� >1 SINK CITY TE(NO. DISHWASHER CONTRACTOR CLOTHES WASHER ADDRESS SWIMMING POOL RECEPTOR CITY TEL.NO. LAWN SPRINKLER SYSTEM STATE LIC. WATER HEATER LICENSE NO. CLASS GAS SYSTEM OUTLETS DISTRICT O. GRO� n PRO S ED BY OUTLETS OVER U Q 5 PER SYSTEM INDUSTRIAL WASTE APPROVAL V INSPECTION RECORD v adO U W O. H z Plan check fee PLUMBING PERMIT ISSUING FEE$ TOTAL FEE Plan check applicant Name .,p APPROVALS DATE INSPECTOR'S SIGNATURE T d UNDER SLAB WORK Address 'e s ROUGH PLUMBING City `T� C—, Tef.No. GAS PIPING I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATIONWITAGAS VENT THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING, HOT WATER HEATER I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS PLUMBING FIXTURES REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE GAS TEST LEGAL OWNER OF.AND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. UTILITY CO.NOTIFIED SIGNATURE OF PERMITTEE FINAL PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION M.O. CASM 2 OrSE� .L2 5 7.5U 0." ©s �i76A667A ICE 8178)-,1 1/76 �� i• _ - / . . 11 "" n_ f f1i1 APPLICATION'FOR.PLUM,B,I,NG *PERMIT * ''BUILDING AND SAFETY DIVISION FOR APPLICANT'TO FILL IA(PRINT ORtTYPE) BUILDING $ NUMBER FIXTU RE OR ITEM ® FEE' ADDRESS WATER CLOSET 1'H�LOCALITYI'� 1 BATHTUB , W NEAREST CROSS ST filli SHOWER r OWNER •MAID'- • LAVATORY, (� ADDRESS ev • SINK, CITY -,TEL NO DISHWASHER CONTRACTOR' CLOTHESWASHER ADDRESS i SWIMMING POOL RECEPTOR 'CITY' - /� TEL NO LAWN SPRINKLER SYSTEM - . ' 'STATE , LIC WATER HEATER LICENSE NO- CLASS GAS SYSTEM OUTLETS DISTRICT NO I ROUP I ZONE OC BY OUTLETS OVER 5 PER SYSTEM INDUSTRIAL WASTE APPROVAL 1A u f t� INSPECTION RECORD u 4Vti.I f^1 Plan check fee" PV. /A, " t VQ z PLUMBING PERMIT ISSUING FEE$ .,TOTAL,FEE 'Plan check applicant + APPROVALS DATE (NSP CFVR'S SIGNATURE Name UNDER,SLAB WORK, —7,7 1 Address ROUGH PLUMBING te City T61 No GAS PIPING I HEREBY'ACKNOWLEDGE THAT I HAVE•READ THIS APPLICATION AND-STATE ,GAS VENT THATTHE ABOVEiIS CORRECT AND AGREE TO COMPLY WITH ALL,COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING' '- • HOT WATER HEATER,' f I HEREBY'CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS, PLUMBING FIXTURES REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I^AM THE GAS TEST LEGAL OWNER OF AND INTEND_TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL 'PROPERTY - UTILITY'CO NOTIFIED SIGNATURE OFPERMITTE FINAL - PLAN CHEGK VALIDATION CK M o CASH PERMITLIDATION cli M O '' CASHlYf ' 4 3.4 c'-'`AUG. 3.5,C AG , ®: WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. r FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING F-1 Certified copy is filed with the county building inspec- ADDRESS /I !�f 4 tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET Date Applicant; NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER 13 O Tis section need not be completed if the work involved b ( hip Y MAIL / CC- Ipermit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS �` l.0 I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. r; so as to become subject to the Workers'Compensation Laws. DISHWASHER (^ CONTRACTOR& r r J�+' �I• r�� 5 l �h Dated Applicant CLOTHES WASHER ADDRESS' NOTICE TO APPLICANT: If, after making this Certificc�ie of SWIMMING POOL RECEPTOR c� a Exemption, you should become subject to the Workers' CITYT . NO Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM C k g— �v with comply with such provisions or this permit shall be STATE .' ,,, LIC. deemed revoked. WATER HEATER LICENSE NO. -> L 5 CLASS C 3c LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER > and Professions Code, and my license is in full force and effect. 1 5 PER SYSTEM FINAL ` DATE ` � - VALIDATION '4 License Number Lic. Class � ` AA_ `` FINAL 9!9Contractor Cyq/D�/�LTIC�i1� Date BY a5 O ❑ I am exempt under Sec. B.&P.C. for this reason Plan check fee Of 17 Date: +` PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the 1 9, 1 A structure is not intended or offered for sale (Section ® x c c o 0 0 5 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 2'',c 3 0,F 0 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued c ° `� 0 Sec. 3097, Civ. C. ( ) �. 05. 14-84 Lender's Name 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 County to enter upon the above-mentioned roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date