HomeMy Public PortalAbout4815 CLOVERLY AVE_Plumbing__ D.B.S.-i; 25M SETS 12-4r, APPLICATION FOR PERMIT
DEPARTMENT OF BUILDING AND SAFETY
COUNTY OF LOS ANGELES PLUMBING 1
WM. J. FOX, CHIEF ENGINEER
NATURE OF INSTALLATION DISTRICT NO. i GROUP ZONE PERMIT NO.
ROUGH FIXTURES _I COMPLETE
HEATER CESSPOOL I SEPTIC TANK RECEIVED BY READY FOR DATE ISSUED
FIRST INSPECTION
GAS M16CELLANEOUB
APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY
JOB �.
E NAME i ADDRESS17
�' ) ,..i' �,:i i,... i... „_ •�
B ADDRESS LOCALITY
f — - --------------- -- ----- --------
D NEAREST
a CITY - TEL. No. _ CROSS ST.
COUNTY
CERT.No. EXPIRES X i NAME 1 !_" n
LOCATION OF SEPTIC TANK, OR CESSPOOL
Z ! MAIL
3 ADDRESS
NORTH O
CITY TEL. No.
I AM THE LEGAL POSSESSOR OF THE ABOVE LOS
ANGELES COUNTY CERTIFICATE OF QUALIFICATION.
PLUMBER
I AM THE LEGAL OWNER OF THE PROPERTY DESCRIBED
ABOVE.
A
3 • OWNER
;-f
CORRECTIONS
SOUTH
a
DESCRIPTION OF WORK
BATH TUB FURNACE �y
rr
_.SHOWER DISHWASHER
LAVATORY REFRIGERATOR
KITCHEN SINK WATER SOFTENER
FLOOR SINK — SAND TRAP
SLOP SINK FLOOR DRAIN
WASH TRAY _ URINAL APPROVALS
WATER CLOSET __ DRINKING FOUNTAIN
DATE INSPECTOR'{NAME
_— WATER HEATER DENTAL LAVATORY ROUGH PLUMBING
METER GAS ...SODA FOUNTAIN GAS PIPING
OUTL
GAS VENT I I `
CESSPOOL
TOTAL NUMBER OF FIXTURES SEPTIC TANK I _
CESSPOOL SEPTIC TANK SEWER
UTILITY CO.NOTIFIED
TOTAL FEE
FINAL
WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm thbt I have a certificate of consent to self 76A667A
insv7e or c cerhhicatL of Workers Compensation Insurance CE 817(REV 10/81) �J
ora certified copy thereof (Sec 3400 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No ' Company11
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
El Certified copy is filed with the county building inspec- ADDRESS
tion department _ _ NUMBER FIXTURE OR ITEM a FEE LOCALITY Z-M L E "/ Y
WATER CLOSET NEAREST
'J
Date Applicant CROSS ST pv - 14-,?:5L/5 tg
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB _-- '
COMPENSATION INSURANCEOWNER - V �/_ � -&
SHOWER
(This section need not be completed if the work involved by MAIL?
the permit is for one hundred dollars ($100)or less ) LAVATORY ADDRESS � _iy
I certify that in the performance of the work for which this -
permit is issued I shall not employ y person in any manner SINK CITY�GLr. h �)�� TEL NO ���b�
so as to become subject to the rk rs Comp ns tion s DISHWASHER ��r7
I
f�� CONTRACTOR
Date l(
App"c 1 CLOTHES WASHER _ 1
ADDRESS
NOTICE TO APPLICANT If fter making this r.er ificat of - R
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth- CITY LAWN SPRINKLER SYSTEM c TEL NO
with comply with.such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO - CLASS
LICENSED CONTRACTORS DECLARATION _DISTRICT O PR9CESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ter, 1
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER i•�
and Professions Code and my'license is in full force and effect 5 PER SYSTEM
FDA
N EL M1 VALIDATION
License Number Lic Class - O
FINAL C.1
Contractor Date BY
0
I am exempt under Sec O
/� W
B&P C for this reason Plan check fee a,
Date
PLUMBING PERMIT ISSUING FEE$ (J ► CO
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
,
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License Address
Law for the following reason (Section 7031 5 Business and
Professions Code) City Tel No _
I as owner of the property, will do the work and the
structure is not intended or offered for sale (Section - - ;@5963A
7044 Business and Professions Code) - - -
CONSTRUCTION LENDING AGENCY - - - # 0 0 0 0 0 5
1 hereby affirm that there is a construction lending agency for _ -
the performance of the work for which-this permit is issued 5- - - - - - J - 31L 5,0
(Sec 3097 Civ C )
P 3 4,5 0
6.
- _
Lender s Name 1. 1 8a86 ,
Lender s Address
I certify that I have read this application and state that the ,® - _
above information-is correct I agree to comply with all County -- - - - x _ �`_
ordinances and State laws regulating Plumbing and hereby -
authorize representatives of this County to enter upon the
ov mentioned pr e for ins ection purposes T ^ '
SEE REVERSE FOR EXPLANATORY LANGUAGE--
Signature of er it 1Il Dat