HomeMy Public PortalAbout9525 BROADWAY_Plumbing__ ✓rte\ f w
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APPLICATION! FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS Broadwa .
WILLIAM A. JENSEN, SUPT OF BUILDING LOCALITY Temple City
FOR APPLICANT TO FILL IN NEAREST T. ftk C OY8
rky
NUMBER FIXTURE OR ITEM
WATER CLOSET 1,25. OWNER
Reardon
ADDRESS
BATH TDB 1,2
CITY 7E1. NO._
SHOWER
1 CONTBACTOR9
LAVATORY
1 SINE ADD Z Chest
nut St.
DrsH"ASREa , crff Monrovia TELNO. EL 9-7134
LAUNDRY TDB REGISTRATION NO. 191691 � COUNTY fs
1 CLOTHES WASHER 1.25 DISTRI NO. GROUP ZONE PR BY
WATER HEATER y
1 GAS SYSTEM O INDUSTRIA U
WASTE APPROVAL,
INSPECTION BECORD i 06
u
/ I W
a
Toa nT, 4-A .e Vjt 11 4< aA4e�KT:?
Si�TA,D�. ,,, T A n as1 S- f
GUn✓.�. T� �oec /yii'l^ L/iilELuirrr r/Y
aQ �R ITEM l� W a c. L1 LcvlEe.r S h�8 eve t� c G p r)
6�yWEEUAE $ APPROVALS IDArE, INSPYECTo/k SIGNATURE
PERMIT $ 2 00 UNDER SLAB WORK
TOTAL FEE ROUGH PLUMBING IIII /ZV if17
GAS PIPING a.'l1D�(,l r/ll14VN O/.
1HEREBY ACKNOWLEDGE THAT 1 HAVE READ "IS APPLICATION ��II
AND STATE "AT THE ABOVE 19 CORRECT AND AGREE TO COMPLY GAS VENT L!`�IogZ [ 0,
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER
PLUMBING. /e
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOSANGELES COUNTY AND STATE OF GAS TEST 'M �O/ •�/Il�
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT PROPER UTILITY CO. NOTIFIED
SIGNATURE P aI U /
OF PERMiTTEF FINAL .2
VAIJDATIPNROBERT A. WOOD v /
CA. SUPERVISING MECHANICAL ENG'R
LHLO 6 5 7 3.tic NOV 7 5 D 1 1 .25-
eb� jCOMPEry( TION DECLARATION APPLICATION FOR PLUMBING PERA IT
nificafe of consent to self 76A667Aays
ce
enr c rhficoiet.of 6V Akers' Compensation Insurance, ' CE B17 (REV,8/86)
ar o 4.R{tled copy Ihenof..4c. 3800, Lab. C.)F . -CO -
UNTY OF LOS' ANGELES- DEPT. OF 'PUBLIC ,WORKS
Policy No - . -IoTpeny - .
❑ - t -
Certified copy is Hrebj furnished."
{, FOR APPLICANT TOIFILL IN{PRINT OR TYPE) BUILDING /- •.
nified copy is'filed with the county building inspec-. - ADD ESS
non departmeN.' ; q',Jr�, / NUMBER FIXTURE OR ITEM @ FEE
DofeCERTIKI ATE OF LOCALITY
ApPliSaQ WATER CLOSET U -NEAREST BATHTUB 1s
'1Z
EXEMPTION FROM WORKERS' oT
-
COMPENSATION INSURANCEoSHOWER OW
-
, NER;
(This section hed net be cbmploted'if work involved by - -
the Permit is for one hundred dollars ($100)or loss.)A . LAVATORY MAIL _ ..
'ADDRESS
certify that in the performance of the work for which this - -
permit is issued, I shall not employ any person in any manner SINK CITY . L TEL. NO. '
so as to become subject to the Workers'{ompehsation Lows. DISHWASHER
CONTRACTOR
Date "Applicant CLOTHES WASHER
NOTICE TO APPLICANT:. If, after making this Certificate of - ADDRESS
Exemption, you should 'become subject to the Workers' - SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code,you must forth- CITU
LAWN SPRINKLER.SVS TE
with comply with such provisions or this permit shall be
deemed revoked ' . / STATE ,� LIC.
WATER HEATER (�C3 LICENSE NO. CLASS
It
LICENSED CONTRACTORS DECLARATION - DISTRICT NO, PROCE ED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing-with,Section 7000) of Division 3 o the Business OUTLETS OVER - (J
and Professions Code,and my license is in full force and effect. '5 PER SYSTEM 'FINAL
t .DATE ALIDATION 'O
License Number J�s �Lic Class_ - _ U
{ l cc
Contracto G Date B .'1' U
❑ Pam exempt under Sec. -, W
. a
B.&P.C, for this reason W
Plan check fee D 2
Date:
.PLUMBING PERMIT ISSUING FEE$
Signature _.
Plan check applicant8.0 28 A
SINGLE.FAMILY -
HOME OWNER-BUILDER DECLARATION Name - - :#'e set • 5
I hereby affirm that I am exempt from the Contractor's License
- -
Low for,the fallowing reason (Section 703 1.5, Business and Address ��( • s'40,50
Professions Code): City Tel. No. 40,5,0 csi
❑ I, as owner of the property, will do the work and the '
structureis not intendedor offered for sale (Section. . - ;D .•0 9,3 0.-87
7044, Business and Professions Code). - -
CONSTRUCTION LENDING AGENCY
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 -
Lenders Address
I certify that I'have read this application and state that the D
above information is correct. I agree to comply with all County ,
ordinances and State lows regulating'Plumbing, and hereby -
authorize representatives of this County to enter upon the - - -
a ve nentione prop" inspection purposes. - -
r ^ �^ SEE REVERSE FOR EXPLANATORY LANGUAGE
,Signature of Permittee Date