HomeMy Public PortalAbout4841 CLOVERLY AVE_Plumbing__ 76A 6874:C-t+817 YA_62
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
WILLIAM A JENSEN, SUPT OF BUILDING LOCALITY
ri
FOR APPLICANT TO FILL IN 3 NEAREST
CROSS ST
NUMBER FIXTURE OR ITEM EACH FEE Z
OWNER
;L WATER CLOSET $125 -s-'o MAIL
BATH TUB 125 I ADDRESS
' SHOWER 125 / CITY TEL NO
LAVATORY 125 CONTRACTOR
SINK 1 25 ADDRESS
DISHWASHER 1 25 ' �� CITY TEL NO�f /� -U0I
LAUNDRY TUB 125 CONTRACTORS �� �7 / STATE 0
REGISTRATION NO / COUNTY
CLOTHES WASHER 1 25 j DISTRICTO GROUP ZONE P OCESSED BY
WATER HEATER 150 + sU 5-"-p
1 50 INDUSTRIAL
GAS SYSTEM OUTLETS (� O
WASTE APPROVAL
OUTLETS OVER 5 PER SYSTEM 30 INSPECTIONrRECOAD 0
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V
W
APPROVALS PATF INSPECTOR S SIGNATOR
PERMIT $ 2 77700 UNDER SLAB WORK v/ l
ROUGH PLUMBING
TOTAL FEE / GAS PIPING
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT Y
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER j
PLUMBING
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO
RESIDE IN THE ABOVE^DESCRI E`D� ESIDENTIAL PEERTY UTILITY CO NOTIFIED 3 !^
SIGNATURE A
OF PERMITTEE
FINAL
ALIDATION ROBERT A WOOD
CK M O CASH SUPERVISING MECHANICAL ENG R
Lp,L0 9 4 4 6 MAR 10 5 D 1 6.25-
)AA,
.25)AA,
76A667 (CE-017)-8-71 �Q � - -(
APPLICATION FOR P MG' PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY
FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST
CROSS ST Ah
NUMBER FIXTURE OR ITEM @ FEE Y1
OWNER r C-000,Md
WATER CLOSET 1 75
MAIL
BATH TUB 1 75 ADDRESS
SHOWER 1 75 CITY TEL NO
r
LAVATORY 1 75 CONTRACTOR Q
SINK 1 75 ADDRESS 11/
DISHWASHER 1 75 CITY TEL NO
CiOU i
CLOTHES WASHER 1 75 STATE LIC
LICENSE NO 034M CLASS
SWIMMING POOL RECEPTOR 1 75
DI$=SICTN �f U�} P E P CESSED BY
LAWN SPRINKLE%R SYSTEM ' 1 75 ��� /v0/ _II
WATER HEATER 1 75 INDUSTRIAL
WASTE APPROVAL
GAS SYSTEM OUTLETS 1 75 _�,NSPE5EION RECORD u
OUTLETS OVER t Z°
5 PER SYSTEM 30 / 0
� U
Lu
0.
r z
t m
Plan check fee See reverse
PLUMBING PERMIT ISSUING FEE $ 3 00
TOTAL FEE (o jQ
APPROVALS DATE INSPECTOR 5 SIGNATURE
Plan check applicant UNDER SLAB WORK
Name ROUGH PLUMBING
Address GAS PIPING
City Tel No
GAS VENT
HOT WATER HEATER
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING GAS`TEST
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR U ILITY CO NOTIFIED If J
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO C` Art/
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY FINAL
SIGNATURE ,lam` '/I
OF PERMITTEE/ 1{ `CIS
PERMIT )f(1. cK M 0 CASH
t PLAN CHECK VALIDATION CK M 0 CASH
WORKER'S COMPENSATION DECLARATION 20 DPW 9189 APPLICATION FOR PLUMBING PERMIT
r� 76A667 '
I hereby afnrm that <#iave a certificate icate of consent to self insure ,
or a certificate of Worker s Compensation Insurance or a certified
copy thereof(Sec 3800 Lab C �-y '/ °
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
Policy No Company y
Certified copy is hereby furnished F❑ BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county budding inspection
department NUMBER FIXTURE OR ITEM @ FEES f LOCALITY
Date Applicant WATER CLOSET L) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST t
COMPENSATION INSURANCE ASSESSOR ✓ `
PAGE PARCEL *2bb
SHOWER MAP BOOK
(This section need not be completed if the work involved by the r'
permit is for one hundred dollars($100)or less) LAVATORY OWNER j
I certify that in the performance of the work for which this permit
is issued I shall not employ any person in any manner so as to SINK MAIL
become subject to the Workers Compensation Laws - ADDRESS 1
' DISWASHER CITY !/ TEL 0
Date Applicant G
PP CLOTHES WASHER f
NOTICE TO APPLICANT If after making this Certificate of CONTRACTOR -
Exemption you should become subject to the Workers Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code you must forthwith comply with such 1 ADDRESS y
provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM _
LICENSED CONTRACTORS DECLARATION CITY TEL NO �-
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
(commencing with Section 7000) of Division 3 of the Business and STATE LIC 0
GAS SYSTEM OUTLETS LICENSE NO CLASS
Professions Code and my license is in,full force and,effect
effect
. V
r ,
OUTLETS OVER DISTRICT NO f PROCESSED BY
, 1 5 PER SYSTEM
License Number Lic Class 1J l�t����� O
DATE /�_�y�b ' VALIDATION a
Contractor Date KC s (n
e8
❑ I am exempt under Sec Q BY AL / .7,7t.IJ e!n Z
,7V OL
8&P C for this reason 1 ITEMSDate Plan check fee - I
Signature PLUMBING PERMIT ISSUING FEE$ O� , TOTAL /75 m 60
't ❑ �
TOTAL FEECHECK 75.66
f SINGLE FAMILY / Plan check applicant , CHANGE t °QQ
HOME OWNER BUILDER DECLARATION Name y
I hereby affirm that I am exempt from the Contractors License Law y - M-0001 1I 4I�6
for the following reason (Section 7031 5, Business and Professions Address wl.r
Code) 7 ` Crty Tel No - r 4043 AM11;Q}
^. I as owner of the property will do the work and the structure
is not mtended or offered for sale (Section 7044 Business -'
and Professions Code) oil.
CONSTRUCTION LENDING AGENCY. A
I hereby affirm that there is a construction lending agency for the r 1
performance of the work for which this permit is issued(Sec 3097
Civ C) -
f
Lender s Name
-
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 ordinances
and State laws regulating Plumbing and hereby authorize
representatives of this County to enter�tlheove meonedpr inspect oses SEE REVERSE FOR EXPLANATORY'LANGUAGE
F �
Signature of Permittee Date