HomeMy Public PortalAbout9159 BROADWAY_Plumbing__ COUNTY OF LDB.ANGELES APPLICATION FOR PERMIT
Department of County Engineer
DIVISION OF BUILDING & SAFETY
WILLIAM J. FOX, County EnOlnaer '
DISTRICT NO. GRjUPI CN / ��6.
FOR APPLICANT TO FILL IN
PLUMBER 3V- C l.. 0 �RE,7vC-+E��IV�E/O•'B^Yh READY FOR GATE ISSUED
C O (_vI NY's FIRST INSPECTION •/ — �3-
ADDRESS (� /� /� T /� /J r
CITY A {� /� '� ' J}• ADDRESS w/
i TEL N0 Ll�{� r
COUNTY •rte/r •fir LOCALITY T C
LICENSE NO. / EXPIRES It1Nl
NEAREST L
PERMIT FEES CROSSST. F Lam. !L1
NUMBER TYPE OF FIXTURE OR ITEM FEE OWNER {ii.(/��Fy rl• �/•
MAIL
WATER CLOSET(TOILET) ® 0.50 $ ADDRESS
BATHTUB ® 0.50 CITY �. 'C TEL NO.
SHOWER ® 0.50 I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS
LAVATORY (WASH BASIN) Q 0.50 APPLICATION AND STATE THAT THE ABOVE IS CORRECT
AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
KITCHEN SINK 0.50 AND STATE LAWS REGULATING PLUMBING.
I CERTIFY THAT I POSSESS THE ABOVE VALID LOS
LAUNDRY TUB OR TRAY ® 0.50 ANGELES COUNTY LICENSE. OR 1 AM THE LEGAL OWNER
OF THE RESIDENTIAL PROPERTY DESCRIBED ABOVE
GAS SYSTEM--OUTLETS 0.50
SIGNATURE OF �� ,J Y�Yt'�/ / ✓�,Y�'-:?
WATER HEATER ® 0.50 PERMITTEE
SLOP SINK 0.50 INSPECTION RECORD v
FLOOR SINK 0.50 _
FLOOR DRAIN 0.50
DISHWASHER O.SO _
DRINKING FOUNTAIN Q 0.50
URINAL 0.50 J
Q
HOUSE SEWER @ 0.50 Z
MISCELLANEOUS - - - - - M
�) ,.L:�.•wr b' /.RSC.LOt�f'-.'�h-:. _ - p -
ly O d
. P 1
APPROVALS
DATE INSPECTOR'S NAME
ROUGH PLUMBING
GAS PIPING
GAS VENT
CESSPOOL @ 1,00 CESSPOOL
SEPTIC TANK! SEPTIC TANK _
DRAIN ( ) PIT ( ) ® /.00 SEWER
PERMIT 1.00 GAS TEST
UTILITY CO.NOTIFIED
TOTAL FEE
FINAL
7GA667 BBS#17 10/i2
` 11
- I.
WORKER'S
haveCOMPENSATIONcertificate
DECLARATION 7BA667 DPW 9/89 APPLICATION FOR PLUMBING PERMIT IJ
]0-0026
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified ,
copy thereof(Sec.3800 Lab.C.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No. - Company
❑ Certified copy is hereby furnished. 1
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is tiled with the county building inspection
ADDRESS � /��+/V✓�
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Dale Applicant WATER CLOSET NEAREST ��(
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST., CS/`x 04
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the SHOWER - MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) LAVATORY OWNER U
I certify that in the performance of the work for which this permit MAIL tV
is issued, I shall not employ any person in any manner so as to SINK ADDRESS
became subject to the Workers'Compensation Laws.
DISWASHER CITY TEL.NO.
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such - - ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM A
LICENSED CONTRACTORS DECLARATION CITY 2/) TEL.NO_04 >_
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER d
(commencing with Section 7000) of Division 3 of the Business and STATE LIC.
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS V
OUTLETS OVERT RICT N (P SSED B QO
�� 5 PER SYSTEM
License Number y� L� Z� Lic.Class (J 1 F
V
FINAL VALIDATION W
DATE a-
�. - I j
Contractor H ¢+ 7� (n
EJI am exempt under Seo. FINAL Z,
BY
B.BP.C.for this reason r
Dale: Plan check fee D
Signature PLUMBING PERMIT ISSUING FEE$ ,
❑ TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOMEOWNER-BUILDER DECLARATION Name Ia�GI .a
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5. Business and Professions Address .'Z`(f IU .IIS
Code):
❑ City Tel.No. 1 ITEMS
I,as owner of the property.will do the work and the structure �{ ��55
is not intended or offered for sale(Section 7044, Business Ti ITAL 20 m 50
and Professions Code). D
CHEL.t, 20.50CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the (:HAI IGE .1311
performance of the work for which this permit is issued (Sec. 3097, -
Civ.C.)
Lender's Name 0000-0001 S/ 711311
~ 2256 1 AN 7:JI3
Lender's Address
I certify that I have read This application and state that the above D
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
properly for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE