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Home My Public Portal About4812 CLOVERLY AVE_Plumbing__ 76A667-CE817-8-58 APPLICATION FOR PLUMBING PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DMSION sUILDING JOHN A. LAMBIE, County Engineer ADDRESS CASSATT D. GRIFFIN,Supt of Building LOCALITY,� I FOR APPLICANT TO FILL IN NEARESTCROSS 2 K/' NUMBER FIXTURE OR ITEM OWNER Z�P. WATER CLOSET BATH TUB ADDRESS SHOWER CITY .. 'TEL. N LAVATORY CONTRACTOR L� SINK ADDRESS DISHWASHER CITY — " NO. CONTRACTOR'S STATE ❑ LAUNDRY TUB REGISTRATION NO. COUNTY ❑ CLOTHES WASHER DISTRICT NO. G OU Z NE 'I ESSED BY WATER HEATER GAS SYSTEMINDUSTRIAL n WASTE APPROVAL INSPECTION RECORD APPROVALS @ $1.00 PER ITEM ' DATE INSPECTOR'S SIGNATURE OR FIXTURE $ UNDER SLAB WORK PERMIT $ 2100 ROUGH PLUMBING TOTAL FEE GAS PIPING 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY HOT WATER HEATER WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING. PLUMBING FIXTURES I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR GAS TEST LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWNER Oy THE ABOVE UTILITY CO.NOTIFIED DESCRIBED RESIDENTIAL RESIDENTIAL PROPERTG SIGNATURE FINAL OFPERMITE1XTE ' /� / " �` ✓ L f 1 VCASH SERT A.WOOD. ®P VALIDATIOPERVISING MECHANICAL ENG'R CK. M.0. s 1,0 3 3 1 5 5 A 3.0 0 ` I i WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby, aff'.-n that I have a- rtificatcf of consent to,self in-' 20-0026 DPW 4/87 n If' i'' 76A667A I'`.JII sure,or a certificate of Workers'Compensation Insurance,ora CE 817(REV. 8/86) certified copy thereof (Sec. 380Q, Lob. C., Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS 1:1Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ,'0 ,.�. Certified copy is filed with the county f.building inspection ADDRESS 11 1� ISR, ",� APE. department. NUMBER•. FIXTURE OR ITEM @ FEE LOCALITY Date Applicant . WATER CLOSET(TOILET] CXO% NEAREST a.- ''� CERTIFICATE OF EXEMPTION FROM WORKERS'. � BATH TUB CROSS ST. ��ILYC4`;? COMPENSATION INSURANCE SHOWER OWNER j7-4/ls��/ (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so CITY TEL. NO. as to become subject to the Workers'�sat DISHWASHER CONTRACTOR �t Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate Ex- SWIMMING POOL RECEPTOR emption, you should become subject to the Workers'Compen- CITY TEL. NO. sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCES D BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER a OA and Professions Code, and my license is in.full force and ef- 5 PER SYSTEM FINAL VAL ATION 0 BATE ect. O License Number Lic. Class 1 U FINAL tS Contractor Date BY O I am exempt under Sec. CL B.&P.C. for this reason Plan check fee , g Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE 00 SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Name 1 Law for the following reason (Section 7031.5, Business anda Professions Code): Address ACCT. F I, as owner of the property, will do the work.and the City. Tel. No. 3307 10 e Ill? structure is not intended or offered for sale(Section 7044, 1 ITEMS Business and Professions Code). ' CONSTRUCTION LENDING AGENCY ► TOTAL �� 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CHANGE (Sec. 3097, Civ. C.). Lender's Name (3CICiD�OL101 i 7 � �I Lender's Address 5110 1 AM11*2 I certify that I have read this application and state that the , 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-mentioned pro or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date