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Home My Public Portal About9609 BROADWAY_Plumbing__ 76 A 667 - CE el] 7H69 APPLICATION FOR PLUMBING PER COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS COLEMAN W. JENKINS. SUPT. OF BUILDING LOCALITY—� FOR APPLICANT TO FILL IN (PR NT OR TYPE) NEAREST CROSS ST. NUMBER FIXTURE OR ITEM EACH FEE OWNER WATER CLOSET L50 MAIL BATH TUB 150 ADDRESS SHOWER 1.50 CITY TEL. NO. LAVATORY 1,50 CONTRACTOR SINK 1.50 ADDRESS DISHWASHER 1.50 CITY TEL. NO. CLOTHES WASHER 1.50 STATE LIC LICENSE NO. CLASS SWIMMING POOL RECEPTOR 1.50 D18TRICT NO. JES11 GROUP ZONE LAWN SPRINKLER SYSTEM 2.00 WATER HEATER 150 INDUSTRIAL d WASTE APPROVAL O GAS SYSTEM OUTLETS 1.50 INSPECTION RECORD U OUTLETS OVER 5 PER SYSTEM .30 Z O 0a N Z Plan check fee 25% of above. See reverse. PLUMBING PERMIT ISSUING FEE S 2 00 iO TOTAL FEE APPROVALS DATE IrvsPEcroRs SIGNATURE Plan check applicant UNDER SLAB WORK Name ROUGH PLUMBING Address GAS PIPING City GAS VENT Tel. No. HOT WATER HEATER I HEREBY ACKNOWLEDGE THAT 1 HAVE REAO THIS APPLICATION ANO STATETHAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS TEST PLUMBING. I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF.AND INTEND TO P RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. FINAL SIGNATURE JACK R. ALLEN, SUPERVISING MECHANICAL ENG'R. OF PERMITTEE �pL PERMIT VALIDATION< y M.o. CASH PLAN CHECK VALIDATION CK. M.O. ASH ��// I �r- 9 8 0 6APR20 5 D 3.50~ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT . � I hereby, affirm that I have a certificate of consent to self in- 20-0026 DPW a/8] ' 76A667A sure,or a ceoll cote of Workers'Compensation Insurance,or a CE 817(REV. 8/86) ,11i4erdfied copy thereof (Sec 3800, lab. C.) COUNTY-OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company a Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING - F] Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM ca FEE LOCALITY WATER CLOSET(TOILET) Date - Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' -BATH TU11 B CROSS ST. = C r vo COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the,work involved by _ - MAIL ]!� the permit is for one hundred dollars ($100) or less.) LAVATORY ADDRESS. ,/ S I certify that in the performance of the work for which this per- SINK mit is.issued, I shall not employany person in any manner so CITY n% `� ' �• TEL NO. ��ry`i, as to become subject to the Workers Compensation Laws. DISHWASHER .. T�ii>>JJ�� CONTRACTOR Date .'Applicant ,5:77, /C P, CLOTHES WASHER gDDRE55 NOTICE O 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 shop be deemed revok- STATE LIC. ed. - - WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO PROyE55ED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS t' ""/) 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and e.Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL _ G VALI TION fe DATE 3 � L License Number Lic. Class U FIN fL Contractor Date - BY / O I am exempt under Sec. W a B.BP.C. for this reason - Plan check fee = Date: PLUMBING PERMIT ISSUING FEE § 2059. 1, A Signature # • • ° is is 5 _ - TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant A •�e 28.5 0 1 hereby affirm that I am exempt from the Contractor's License Name Low for the following reason (Section 7031.5, Business and s a - 2a50'0 Professions Code): Address I, as owner of the property, will do the work and the City Tel. No. O 9, O 8 8 v-' structure isnot intended or offered for sale(Section7044, - Business and Professions Code). CONSTRUCTION LENDING AGENCY , c 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 , Lender's Address I certify that I have read this application and state that the a lop, information is correct. I agree to comply with oil County ordinance's and State lows,regulating Plumbing, and hereby , authorize representatives of this County to enter upon the ' abovfi ed pro er r.{or inspection purposes. �� ,/7�a 0 SEE REVERSE FOR EXPLANATORY LANGUAGE gnoture Permittee ,/ Date