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Home My Public Portal About4930 CLOVERLY AVE_Plumbing__ 76A667A r CE 8 V(REV 6/78) q�s f APPLICATION FOR PLUMBING PERMIT _COUNTY OF LOS ANGELES BUILDING SAFETY FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ADDRESS 'y NUMBER FIXTURE OR ITEM ® FEE LOCALITY WATER CLOSET NEAREST BATH TUB CROSS ST Ct— SHOWER OWNE LAVATORY MAIL ADDRESS SINK CITY ' TEL NO DISHWASHER CONTRACTOR CLOTHES WASHER ADDRESS SWIMMING POOL RECEPTOR j CITY TEL NO D AWN SPRINKLER SYSTEM STATE LIC WATER HEATER LICENSE NO �a CLASS GAS SYSTEM OUTLETS f APPROVALS DATE INSPECTOR S SIGNATURE OUTLETS OVER UNDER SLAB WORK 5 PER SYSTEM ROUGH PLUMBING GAS PIPING GAS VENT @S HOT WATER HEATER PLUMBING FIXTURES GAS,TEST 1 Ub Plan check fee UTILITY CO NOTIFIED' PLUMBING PERMIT ISSUING FEE$ TOTAL FEE FINAL Plan check applicant PLAN CHECK VALIDATION Name' Address City Tel No I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES I AND STATE LAWS REGULATING PLUMBING PERMIT VALIDATION � 1 t 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS .. REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE O O O O O 5 LEGAL OWNER OF AND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL (� PROPERTY ? 2 0 0 7 Q 0 0 t v. t SIGNATURE O O O 1 0 0 0 i OF PERMITT DISTRICT NO PR CUSSED BY 0 602-79 INDUSTRIAL WASTE APPROVAL DBDEAeS I7'DIII , APPLICATION FOR PLUMBING PERMIT ,1 SION OF BUILDING AND SAFETY Deportment of County Engmeer County of Los Angeles BUILDING JOHN A LAMBIE COUNTY ENGINEER ADDRESS CASSATT D GRIFFIN, SUP T OF BUILDING LOCALITY FOR WLICANT TO F L IN NEAREST CROSS ST OWNE DIST NO I GROUP I READY FOR INSPECTION MAIL ADDRESS:- INDUSTRIAL CIT TEL O WASTE APPROVAL PLUMBER INSPECTION RECORD ADDRESS ciI1 CITY EL NO K LICENSENOy NUMBER TYPE OF FIXTURE OR ITEM FEE WATER CLOSET (TOILET) @ $1 00 $ BATH TUB @ $100 / SHOWER @ $100 LAVATORY (WASH BASIN) @ $100 ` KITCHEN SINK @ $100 DISHWASHER @ $1 00 LAUNDRY TUB OR TRAY @ $1 00 CLOTHES WASHER @ $1 00 WATER HEATER @ $1 00 GAS SYSTEM @ $100 APPROVALS DATE INSPECTOR S SIGNATURE UNDER SLAB WORK PERMIT S 7 00 ROUGH PLUMBING lO GAS PIPING TOTAL FEE . L GAS VENT I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION HOT WATER HEATER AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY �} WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING PLUMBING FIXTURES 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR GAS TEST k U LICENSED AS REQUI ED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR A 1 AM THE LEGAL OWNER OF THE ABOVE UTILITY CO NOTIFIED v- DESCRIBED RES ENTI ROPER SIGNATURE OF PERM ITT FINAL JOHN A LAMBIE CO Y ENGINEERALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR CK M 0 CASH . o 0.3 9 A SEP11 3 12.00 In s • !• WORKER'S COMPENSATION DECLARATION 200026 DPW 9/89 APPLICATION FOR PLUMBING PERMIT 'a 76A667A I hereby affiin that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified copy therBof(Sec.3800 Lab. C.) y � C LV+� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. PolicyNo. �/ Compan ❑ Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING r ►y,�O /�(_,,, L)� Certified copy is filed with the county building inspection ADDRESS �•("7 de artm nt. NUMBER FIXTURE OR ITEM FEE LOCALITY Pyvi�, Date r Applicant Vt� _ j WATER CLOSET NEAREST 'l c CERTIFICATE OF EXEMPTION FROM WORKERS' ` CROSS ST. COMPENSATION INSURANCE ASSESSOR / / (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE `�( PARCEL (/w permit is for one hundred dollars($100)or less.) OWNER '54t UA F_5u• i V)17- _TV 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to MAIL �O become subject to the Workers'Compensation Laws. ADDRESS L t� DISWASHER CITY TEL.NO. Date Applicant CLOTHES WASHER t O NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY ,�` TEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000) of Division 3 of the Business and STATE LIC. (-_7 ' o Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS < OUTLETS OVER DISTRICT NO.// PROCESSED BY a: 2—C6 � T 1'9— ,,7 5 PER SYSTEM A l_ �y Q License Number ` r t7!75 Lia Class ivy FINAL W/ �. j VALIDATION Contractor �I C.14�yrN 171 - Date DATE ❑ FINAL Z I am exempt under Sec. BY B.&P.C.for this reason Plan check fee , �Date: Signature /�' j PLUMBING PERMIT ISSUING FEE$ ❑ TOTAL FEE - Plan check applicant SINGLE FAMILY '_:t,1 g HOME OWNER-BUILDER DECLARATION Name ^ I hereby affirm that I am exempt from the Contractor's License Law t_y,:f „ for the following reason (Section 7031.5, Business and Professions Address Code): F1 1, Tel.No. I, as owner of the property,will do the work and the structure 20 = -_�a is not intended or offered for sale (Section 7044, Business and Professions Code). , i.HC--FL CONSTRUCTION LENDING AGENCY IS� f3 .01311 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ.C.) Lender's Name �t 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 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 1