HomeMy Public PortalAbout4850 CLOVERLY AVE_Plumbing__ 7BA607-CE817 10-60
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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AM SAFETY DMSION BUILDING j O
JOHN A LAMBIE. COUNTY ENGINEER ADDRESS
WILLIAM A JENSEN, SUP T OF BUILDING
LOCALIPY
FOR APPLICANT TO FILL IN NEAREST
Os ST
NUMBER FIXTURE OR ITEM OWNER 0
/ WATER CLOSET X11
/
BATH TUB ADDRESS
CITY TEL NO
SHOWER + ,`
LAVATORY CONTRACTOR ,#M
ADDRESS D J!' /� / c
r
SINK
DISHWASHER CITY NO
CONTRACTOR'S /� STA
LAUNDRY TOB REGISTRATION NO , 7 COUNTY
CLOTHES WASHER DISTRICT NO GROUP ZONE SSED BY
WATER HEATER ! L
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL r
,f INSPECTION RECORD_ D'
o.
11
$I oo PER ITEM I �}�
OR 1•I1CTjTRE $ 7 e 0,0 APPROVALS DATE - INSPECTOR S SIGNATURE
PERMIT $ 2100 UNDER SLAB WORK
TOTAL FEE ROUGH PLUMBING
GAS PIPING 1
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING HOT WATER HEATER A �.
1 HERESY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES ' /„j p 11 T`('/J;,f(
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST ' "�/� J(t/1�`�J` 7
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DEBCR IBED REBIDENTI PROPERTY . i •'
UTILITY CO NOTIFIED
SIGNATURE
OF PERMITTE
FINAL
VALIDATION ROBERT A WOOD
cK M O CASH SUPERVISING MECHANICAL ENG R
r+ yE? $ 3 6w .tel 9 5 D 9.00 r~
WORKERS' COMPENSATION DECLARATION .x
200026 DPW{4/87 APP,LI,CATION FOR PLUMBING PERMIT -
I hereby, affym that I have a certificate of consent to self In- _76A667A
sure,or a certificate of Workers Compensation Insurance,or a CE 817(REV 8/86) k; i
certified`edpy thereaf (Sec 3800 Lab C -
Palk No/8 J� /_� f c�any S~Y + COUNTY OF'LOS`ANGELES v- 'DEPT OF-PUBLIC WORKS] `^ "r
'""' r" he'r'eby
W ti'y>'R
_ Certified copy is hereby furnished - , iz
i $ FOR APPLICANT TO FILL IN (PRINT OR TYPE) ' BUILDING /I(Jf �
1`
Certified'copy is filed,with the county building inspection ADDRESS `7(�J
1dep8riment 1 NUMBER, a 5 FIXTURE OR ITEM Llan, y• FEE, LOCALITY
WATER CLOSET (TOILET)
Date Applicant - NEAREST F r
+ f f i c e BATH TUB �, CROSS ST L..-Pz,-
CERTIFICATE
OF EXEMPTION FROM WORKERS � � x ,
rCOMPENSATION INSURANCE' _ OWNER
.-v ,G ti"�. �c r 1 e �SHOWEdR ,��: - r r , ., p,
(This section n'e'ed not be completed if the,wo�Virivolved by," _ MAIL
the permit`is for one hundred dollaii($100)or less ) LAVATORY - ADDRESS
I cerhfy�that in the performance of the work for which this ea- a
3_ r a^ b r s r p SINK` Y _-11 r "a _ f vc
'm, is issued-I shall not employ any person in any manner so "�� 'a e +' - ,_CITY r ^ TEL NO'
as to`become�sublect to the Workers CompensationLaws` t DISHWASHER
't n7r 1Y a .3fi } r 41 r ti d CONTRACTOR .97 MAN
Date` ' Applicant ' r CLOTHES WASHER [��y
' ADDRESS_I 7 Uf 7� I,
NOTICE TO APPLICANT rf-�after,making'thirCertific6te of Ex- wSWIMMING POOL RECEPTOR `< ,
-emption,you should become subject t6<tPie Workers Compen-
cation provisions of the L6tior Code you must forthwith comp y1_AWN,SPRINKC SYSTEM e CIT�� `/. F�
tl'y with such provisions or.this permit'shall be`deemed revok STATE v� �� ��� LIC
'
ed,., `• r ` , a;, r' a e a, 4 ?' ' 'WATER HEATER"'_ k " LICENSE`110 �j '
` ` s� CLASS
t :a 'LICENSED CONTRACTORS DECLARATION '' r DISTRICT Nq PROCE D B
> GAS SYSTEM ~�F O Q`= r
'Pher" affirm that I,am licensed under provisions of Chapter _ d OUTLETS
9(commencing with Section 7000)of Division 3 of the Business - OUTLETS OVER ' ° s `
and Profess16ns'Code and my license Is in full force and of 5 PER SYSTEM - FINAL " VALIDATION'
dfect K '` (� !/j7s eS< w DATE O>
,.License Number c L c'Class V,
et � � ALcc
BY OContracio '
1, V
r I am exempt under SecWV
B 8P'C'for this reason
Y ti+ - Plan check fee,} g
Date + PLUMBING PERMITrISSUING FEE$ -
Signature < 2 t
a OTAL FEE
SINGLE FAMILY
` HOME OWNER-BUILDER DECLARATION Plan check applicant - �< 5-; '
- - -
Ihereby'affirm,that,I,am exempt from the Ccntractor's,Lcense a Name, „, " wr
Law for thewfollowing reason (Section47031 5 Business and '. 1 it °° °` ' 4Ts7
'Professions,Code) y x Address �.t��J '/y �f
'7',,,^ Y ) 'A�' ,a+.y;y a ,+ ` V .. ` �°w yF ,^ �'28. 0
I;aas"owner of the property will do the work and,the City, +� ," Tel No °^ �'ey ° �` r _ 4 1ITEMS ' �}
structure'Is not intended or offered for sale(Section 7044, TrC
- `Business and Professions,Code
= CONSTRUCTION'LENDING:AGENCY ?x,� z ° - wi• 'CHECK - 2a.`+0
Ir hereby affirm that thele Is a constructwn lending agency for co`' _ 6 _ * L,
e,
the performance of the work for `which this permitris issued 1Y f - , - f' s- g n C��'
-'(Sec '3097 Civ C j /
'
i _ w It)Q- Q1 9/22149
Lende"r s Name r
� e�` ,��a+ _ <y,,. � ai_. ,' �e• t KY ,��;r a, t `
F ff 1 AM 8:194Lenders Address < ��
-
I certify that'I hove,read this application and state that the
above Information Is correct I agree'to cornply'with all County V," N ;�i,� e > ✓ - - 3 , v
ordinances and State law's regulating'Plumbing'and hereby
g,n "�representatives of this�County io3enter upon the
entio d p p y for"i e nypurpo's s ` < r �'Gt .`SEE REVERSE FOR EXPLANATORY LANGUAGEe of'Permittee ''Date 4
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