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I 76A667-C[M017 6-66
' APPLICATION FOR PLUM IN PERMI
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION IIIII.DDIa MCW4 Av
JOHN A. LAMBIE, COUNTY ENGINEER ADDIa�s /Z C
COLEMAN W. JENKINS. SUPT. OF BUILDING LOCALIT! /M?,16 Ct
FOR APPLICANT TO FILL IN OROS DT. c �J'h
NUMDIEt FIVURI OR MILM [ACH FI[ �� T� M /
WATER C OZEr 1111ZOwl=
1Z Z Ow 6 7� b{ /�
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RATH TUR 1.8 ADD=FJ�� 7 C G6IA 4 Vv
SHOWER 1 ti crry TEM/°L� L 7Y TEL NO.7-F6-2 Y61/
LAVATORY im ! CONTRACTOR o(,v
rm 113 ADDEM
DISHWASHER im cm TEL NO.
STATE L I C
LAUNDSY TUB 1J� LICENSE NO. CLASS
CLOTIM WASHER 1J5 DISTRICT N0. ORQUI• ZON[ P [D ■Y
WATER HEATER 1.50
SAS STSTEH OUTLE11 1.50 DMS' CL
WASTE APPROVAL
OQTLETR OVER f PER ■TSTEH .30 UC&PZCT1OX RECORD O
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APP"OVALS DATE INSP[CTOR'•XIGNATURK
rERM1T i 2 00 UNDER SLAB WORK
ROUGH PLUMBING
TOTAL FEE GAS PIPING
II
H[1110Y ACICNOWLZDQt THAT I HAVI[ READ TWIG APPLICATION GAS VENT
AND STATI< THAT THI ABOVE 15 WIIIRCT AND AGREI TO COMPLY
WTTH ALC`50UKTY ORDINAMCZ
/ AND STATE LAWS REGULATING HOT WATER HEATER
PLUMS1 ING.
I MUMMY CERTIFY THAT I AM PwoP=RLY RIIGIST[RED AND/014 PLUMBING FIXTURES
LICENSED AM REQUIRED MY LOS ANGSL[S CGOUNTY AND STAT[ OF
CACJFO#tN A OR THAT 1 AM THE LEGAL OWNER OF,AND D TO GAS TEST
REVD[ IN,THE z'qIS[D RSJIDSNTIAL P P[RTY UTILITY CO.NOTI IED -
SIGNATUR¢
OF P[RMITTI[
FINAL
III ATION
CK. M.O.
1 3 8 9Z3 AM 1 9 5 D 7,2 5
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`"°R'�s"C°'"�"SA"°" D 'n°'' APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certtflcatp of consent to self 76A667A
Insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
or a cartlf��I c the` (se`' ' C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Nd4-r� � Company
❑ Certified copy If hereby furnished.
FOR APPLJC11JT TO FtLL iN(PRINT OR TYPE) BUILDING _
` 53--tertlfied copy Is filed with the co my build[ [nspeC- ADDRESS
eLE
tion department. NUMBER FTXTURE OR ITEM FEEELOCALITY
Date — Appli ant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPT1 N FROM RKERS' BATHTUB CROSS ST'
CON ENSATION INSURANCE SHIOWE1t OWNIEt
(Thu section roved not be completed If the work Involved by
AR
the permit Is for one hundred dollars(;100)or lea.) Ls,VATORY ADD
ADD{2FS5
I certlfy that In the performance of the work for which this
permit Is Issued, I shall not employ any person In any manner SINK CITY TEI- NO.
so as to become subject to the Workers'Compensation Lawn. L3IShNVA51iER
coNTRACTOR N -r
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL TOR
Exemption, you should become subject to the Workers TEL Compensation provisions of the Labor Code, you must forth- LAWN SIR IIW�SYSTEM
with comply with such provisions or this permit shall be STATE es: LIC
deemed revokeEN
d. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATIONBY
I hereby affirm that I am licensed under provislors of Chapter 4 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Bus[nea OUTLETS OVER f
and Professions Code,and my license Is In full force and effect. 5 PER SYSTEM Axe DATE VALIDATION U
License Number c. Clan T
n r Q1
/Vey FINAL r+-
Contractor Date BY4V i
I am exempt u er Sec. P V, rA
B.BP.C. for this reason
• _ Paan check fee
Date:
PLUMBING PERMIT ISSUING FEE j
Signature -
TOTAL EEE
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name 1 0 2 2 7 A
I hereby affirm that I am exempt from the Contractor's License ss Addre
Law for the following reason (Sectlon 7031.5, Business and ��
Professions Code): CI Tel0 0 0 0 5
. No. OtJ
❑ 12"-i- 2r1, as owner of the property, will do the work and the 8'50
structure Is not Intended or offered for sale (Section , r
7041, Business and Profmslorm Code). 0 0 0 2 a'5 0 ZTS
CONSTRUCTION LENDING AGENCY 03-071-83
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is issued
(Sec. 3097, Cly. C.}
o
Lender's Name
Lender's Address
I certify that I have read this application and cote that the 1�
above Information is correct. I agree to comply with all County
ordlnancee and State laws regulating Plumbing, and hereby
authorJze representatives of this County to enter upon the
abo entlo pro for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Ignature of Permlttee Date
COUNTY OF LOS A9GELu9 TEMPLE CITY # 0508 PLUM13ING PERMIT
DEPARTMENT OF PUBLIC MORES 9701 LAS TUNAS PL 0508 1212180025
_ BUILDING AND SAFE'T'Y / LAND DEVELOPMENT T•EX" CITY CA 91780
PHONE: (626) 285-0488 ETT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 15683 LT: 89 5129 CAMELLIA AV
FEE DESCRIPTION: QUANTITY: DOM: AMOUNT: TEMP CA 917803856
ASSESSOR INFOR14ATION NUMBER: NLUZEST CROSS STREET:
8589-013-011 01 PERMIT ISSUANCE FEE 27.80 TUM S PAGE: 597 GRID: A4 LOCALITY: T124 •F CITY CA
47 MATER HEATER(S) 1.00 WTH 16.20
TENANT: TOTAL FEES 44.00 ISSUED ON: PROC SSUD BY: PLAN BY:
12/18/12 SR
OWNER: TEL. NO: TpF Y: CODE:
HAMKE9 JEROME ITALIC& TRUSTEES (626) 426-8125-
51 (29 AMELLIA AV
TEMP 917803856 D OF WORK
REMOVE/REPLACE GAS MATER HEATER BASEMENT 40 GAL/.62 EF
APPLICANT: TEL. NO:
MARTINEZ, NICK (323) 440-2069-
12601 132 AVE NE SPECIAL CONDITIONS:
KIRKr.MiD KA 98034
CONTRACTOR: TEL. NO: APPROVALS DATE INSPEt"'MR SIGNATURE
FAST MATER HEATER PARTNERS ILP (425) 636-7054-
12601 132ND AVE NE LIC. NO LENDER -SLAB STORK
IZRKLANO WA 98034 931237 +
toLTSY SERVICE
PLASTIC Y/N METAL Y/N
ARCHITECT OR ENGINEER: TEL. NO:
_ ROUGH PLUMBING
LIC. NO:
GAS IPIING
GAS VENT
HOT yATER HEATER
PLUMING FIXTUR.FS
LATIN 9 PR,IN]aBRS .
GAS TFi9T
U=ITY COMPANY NOTIFIED
CNV
GRAY PAPER SYSTEM
+ ADDITI0i2AL DATA ON FILE
REPORT ID: DPP-263 ROUTE TO:' B90508