HomeMy Public PortalAbout4540 CLOVERLY AVE_Plumbing__ rr . COUNTY OF LOS ANGELES APPLICATION FOR PERMIT
Department of Engineer 1
DIVISION OF BUILDING & SAFETY
WILLIAM J FOX, County Engineer
FOR APPLICANT TO FILL IN
DISTRICT GROUP ZONE PERMIT
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PLUMBER Belvedere Plumbing CO RECEIVED BY READY FOR DATE ISSUED
L FIRST INSPECTION
ADDRESS 136 SO. Palm Ave. V
UILD
DITY Alhambra TEL NO AT 95025 BADDRE9S
6 N. Cloverly Ave.
COUNTY LOCALITY Temple Cit
LICENSE NO 808M EXPIRES 6-30-53
NEAREST
PERMIT FEES CROSS ST
NUMBER TYPE OF FIXTURE OR ITEM FEE OWNER George R. Knittle
MAIL
1
WATER CLOSET(TOILET) 050 $ 05U ADDRESS
Z BATH TUB @ 050 5 CITY TEL No
SHOWER 050 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS
Z LAVATORY (WASH BASIN) O 50 APPLICATION AND STATE THAT THE ABOVE IS CORRECT
AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
KITCHEN SINK @ 050 O AND STATE LAWS REGULATING PLUMBING
I CERTIFY THAT I POSSESS THE ABOVE VALID LOS
LAUNDRY TUB OR TRAY @ 050 -50 ANGELES COUNTY LICENSE, OR 1 AM THE LEGAL OWNER
O OF THE RESIDENTIAL PROPERTY DEBC BED Aj OVE
GAS SYSTEM OUTLETS @ O SO
SIGNATURE OF 4
WATER HEATER @ Oso p 5O PERMITTEE
SLOP SINK @ 050 INSPECTION RECORD
FLOOR SINK 050 /� ������ �/✓5,�
FLOOR DRAIN Q O 50
DISHWASHER 050
DRINKING FOUNTAIN (B O SO
URINAL @ Oso
Q
HOUSE SEWER @ O 50 Z
0
MISCELLANEOUS
0
APPROVALS
DATE IN1SPPE�CyTORI B NAMES
ROUGH PLUMBING `--'-'—
GAS PIPING
GAS VENT
CESSPOOL @ IO0 CESSPOOL
SEPTIC TANK SEPTIC TANK
DRAIN ( ) PIT ( ) @ 1 00 SEWER
PERMITt 0❑ GAS TEST
UTILITY CO NOTIFIED _
TOTAL FEE jl 50 1 FINAL ,r-�S
76A66: D13S#17 6-52 8SM
0
e
� �.WORKERS' COMPENSATION DECLARATION
J hereby,affirm that I have a certificate of consent to self in- 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
76A667A '1 I
sure, or a certificate of Workers'Compensation Insurance,ora CE 817(REV. 8/86) U
certified copy thereof (Sec. 3800, Lab. C.) _ _ COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company_
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS
NUMBER FIXTURE OR ITEM LOCALITY
deportment. ,[_�� -�-�•'�. @ FEE
Date 13-- Applicant &1]lr'y �C`'{dlG `/CATER CLOSET(TOILET) OO NEAREST c+
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE ` OWNER SHOWER
(This section need not be completed if the work involved byMAIL.
the permit is for one hundred dollars ($100)or less.) / LAVATORY ADDRESS S(J CLO V�
I certify that in the performance of the work for which this per- �fJ
mit is issued, I shall not employ any person in any manner so SINK. CITY e TEL. NO. 7 7
as to become subject to the Workers' Compensation Laws. DISHWASHER 1
CONTRACTOR �^
Date Applicant CLOTHES WASHER
ADDRESS L
NOTICE TO APPLICANT: If, after making this•Certificate of Ex- Al,
emption,you should become subjeci to the Workers'Compen- SWIMMING POOL RECEPTOR
sation provisions of the Labor Code, you must forthwith comp- CITY
TEL NO.
P Y P- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. 3 B CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P OCESSED BY
I hereby affirm that I am licensed under provisions of Chaptei GAS SYSTEM OUTLETS ` it
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER V
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL J VALIDATION
fect. DATE
License Number Z Lic. Class_lam V
FINAL
r,�
Contractor J f Eate r8J BY 1� ;`�
t=
I am exempt under Sec.
B.&P.C. for this reason
3 Plan check fee ® g
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
INGLE AMILY Plan check applicant
HOME OW ER-BUILDER DECLARATION PP
I hereby affirm that I am exempt from the Contractor's License Name "
Law for the following reason (Section 7031.5, Business and ,^ y
Professions Code): Address k w r 1 _4.
ETI, as owner of the property, will do the work and the City Tel. No. " `" _ z
structure is not intended or offered for sale(Section 7044, -. ;z
i
Business and Professions Code). ® } TAkJ
=e
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the wofk for which this permit is issued
(Sec. 3097, Civ. C.). "-
Lender's Name _
Lender's Address
> >a._
I certify that I have read this application and state that the
above information is correct. I agree to comply with.all County
ordinances a,nd State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentione roperty for i pection purposes.
..L3,gay SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature f Per ttee Date