HomeMy Public PortalAbout4804 CAMELLIA AVE_Plumbing__ WORKERS'COMPENSATION DEC:ARATION APPLICATION FOR PLUMBING
d'e IDERMIT
„I hereby affirm that I hove a certificate of consent to self 76A667A 'k.r PP99 00 ISI CYII u II'( r IL tLYYHNID CCI`L9 Ir IG PtYtlE 0
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.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) 8UILDI SS `
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM a LLFEE LOCALITY ��G�-
Date Applicant WATER CLOSET L' t NEAREST r
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. �� /J �L✓�
COMPENSATION INSURANCE SHOWER OWNER.
(This section nerd not be red leteddolga if the work involved by — MAIL j/(i''J� - /• // j q ,QJ�
the permit t for one hundred dollars e war or less.)hi LAVATORY / ADDRESS
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;7-!7 �, TEL. NO.
so as to become subject to the Workers'C mpensotion Laws. ZDISHWASHER ^ `•'
CONTRACTOR
Dat'?
Applico G` - CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers SWIMMING POOL RECEPTOR /
Compensation provisions of the Labor Code, you must forth- CITY ! > G TEL. NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit-shall be STATE IIC.
deemed revoked. WATER HEATER LICENSE NO.3�=Z�2 CLA
LICENSED CONTRACTORS DECLARATION DISTRICT NO.-/ R ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ✓ S Q Cy
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER c
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM )"
DATE — _/y7 VALID TION 0
License Number��'r'�'• �` LiorClau / c/7 V
(} FINA
Contractor ate BY 0
❑ V
am exempt under Sec to
d
B.BP.C. for this reason - W
Plan check fee D _ Z
Dale. / ;2 1 761 A
- PLUMBING PERMIT ISSUING FEE S
5"gnartue
TOTAL FEE # e e e e e 5
SINGLE FAMILY Plan check applicant d •( e - 4050
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address e e e 4 0 5 0
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. _ {� �j 2 9 trp 5
El1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section D
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY _
I 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 Nome
Lender's 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 laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-m on d'li b�erty for b�pectlon purposes.
��L�e SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date D"r—/
= 0.8.9.17 2SM 9ET8 10.47 APPLICATION FOR PERMIT
DEPARTMENT OF BUILDING AND SAFETY
COUNTY OF LOS ANGELES '
Wm.J. FOX, CHIEF ENGINEER
NATURE OF INSTALLATION DISTRICT NO. GROFEJ c1 / O..7/
ROUGH FIXTURES COMPLETE g-177 � J �Jr! /
READY FOR HEATER CESSPOOL SEPTIC TANK RECEIVED BY DATE ISSU6d
J� �� PIRBT INSPECTION `3 — 1
AS MISCELLANEOUS
APPLI90T FILL IN HEAVILY OUTLINED PORTION OPjLY
JOB Dw N ADDRESS
Wtt
M
ADORE" LOCALITY
g
J ' �• NEAREST
L CI _ TEL.N i CROSSST.
COUNTY
'
CERT.No. J� EXPIRES L C NAME
LOCATION 6FSEPTIC TANK, OR CESSPOOL 2 MAIL
3 ADDRESS
NORTH 0 /
CITY TEL.No.
I AM THE LEGAL 8880R OP NE BOVB LOS
ANGELES COUNTY CERT 1 B[aR qU IP - TION.
!//(O/
PLUMS"
1 AM THE LEGAL O ER OF THE PROPERTY.DESCRIBED
ABOVE.
s
3, 19 OW NHq
Y CORRECTIONS
SOUTH J
DESCRIPTION OF WORK i
BATH TUB FURNACE
'HOWER DISHWASHER D
LAVATORY REFRIGERATOR
_/—KITCHEN BINK WATER SOFTENER
FLOOR BINK SANOTRAP
SLOP BINK FLOOR DRAIN
-WASH TRAY URINAL APPROVALS
WATER CLOSET DRINKING FOUNTAIN DATE CINSPECTOR'S NAME
WATER HEATER DENTALLAVATORY I✓`� I /�
/ ROUGH.PIUNBING L-
METER-5—CAS SODAFOUNTAIN
OUTL GAS PIPING I I
GAS VENTI I
CESSPOOL I
GTOTAL NUMBER OF FIXTURES SEPTIC TANKWI I
CESSPOO, SEPTICTANK r SEER I I
S UTILITY CO.NOTIFIED I V _ I _
TOTAL FEE /_.1 FINAL
• •t/��Y
—lI
76A667 (CE-B 171-4/72
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
STAKE CHECKS PAYABLE TO: BUILDING /
ADDRESS
HARVEY T. BRANDT, COUNTY ENGINEER LOCALITY
t
FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST /
CROSS ST.
NUMBER FIXTURE OR ITEM @ FEE
WATER CLOSET 1.75 OWNER tiGl
MAIL
BATH TUB 1,75 ADDRESS �.
SHOWER 1.75 CITY TEL. Nq.2j- /Q ACJ/
LAVATORY 1,75 CONTRACTOR
SINK 1.75 ADDRESS
DISHWASHER 1.75 CITY TEL. NO.
CLOTHES WASHER 1.75 STATE / LIC
LICENSE NO. CLASS
SWIMMING POOL RECEPTOR 1,75
DISTRICT NO. GROUP ONE CESS D B
LAWN SPRINKLER SYSTEM 1.75
/ WATER HEATER 1.75 INDUSTRIAL �r
WASTE APPROVAL d
GAS SYSTEM OUTLETS 1.75 INSPECTION RECORD
OUTLETS OVER C
5 PER SYSTEM .30 p
U
W
1
H
Z
Plan check fee See Reverse
PLUMBING PERMIT ISSUING FEE S 3 DD
TOTAL FEE
APPROVALS DATE 1!IS PEC TOR'9 SIGNATURE
Plan Chef pl Kant UNDER SLAB WORK
NE INROUGH PLUMBING
Address GAS PIPING .
City TeL O. GAS VENT
HOT WATER HEATER �
Fi7 a/�'� tT
ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION _
AND STATE THAT THE ABOVE IS CORRECT AGREE COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATETE LAWS REGULATING
PLUMBING. GA$ TEST
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED
LICEYSED AS REQUIRED BY L05 ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO _
RESIDE IN THE ABOVE DESCRIBED FIESIDENTIA OPERTY. FINAL
SIGNATURE —II\' ,
OF PERMITTE Cl
PERMIT VALIDATION CK. M.Q. CASK
PLAN CHECK VALIDATION CK. M.a. CASH
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742i;Nu 5 U 4.75 A%