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Home My Public Portal About4935 CLOVERLY AVE_Plumbing__ 76A667-CE817 6-60 APPLICATION FOR PLUMBING PERMIT � COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A LAMBIE, COUNTY ENGINEER ADDRESS WILLIAM A JENSEN SUP T OF BUILDING / LOCALITY FOR APPLICANT TO FILL IN NEAREST CROSS .C1 NUMBER FIXTURE OR ITEM OWNER WATER CLOSET p MAIL �.-5 v / BATH TUB CITY 2� NO i a SHOWER + CONTRACTOR LAVATORY SINS ADDRESS DISHWASHER CITY TEL NO CONTRACTOR S STATE ❑ LAUNDRY TUB REGISTRATION NO COUNTY CLOTHES WASHER DISTRICT NO GRO P ZONEI P CSD BY WATER HEATER a Dkza �- GAS SYSTEM INDUSTRIAL WASTE APPROVAL INSPECTION RECORD P. O U O NUU W� N Y Q 81 W PER TEEM OR FISTUBE $ / APPROVALS DATE INSPECTOR S SIGNATURE PERMIT $ 2 00 UNDER SLAB WORK TOTAL FEEROUGH PLUMBING GAS PIPING // 7 CAo 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY s. GAS VENT WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING HOT WATER HEATER 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 OWNOF THE ABOVF.� DESCRIBED RESIDE IAL PROPERTY UTILITY CO NOTIFIED SIGNATURE OF PERMITTE FINAL ®r J 6a. VAf 0. cAra SUOPERV S NG MOECOHANICAL ENG R I 4 5 D �� `` `J rdt�Id `W°4K`. S' °MPE"sAT'°" DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby, offitm.that I have a certificate of consent to self in- 76A��A PW 4/90 sure,o;a certificate of Workers'Compensation Insurance,or a n certified copy thereof (Sec. 3800, Lab.,C.) U COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company {.. Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ^� J ❑ Certified copy is filed with the county building inspection ADDRESS V department. NUMBER FIXTURE OR ITEM @ FEE LOCALITYP � ! Date Applicant I WATER CLOSET(TOILET). 7 NEAREST BATH TUB J! CROSS ST.� CERTIFICATE OF EXEMPTION FROM WORKERS' / COMPENSATION INSURANCE SHOWER OWNER ^ (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars $100 or less. LAVATORY ' p ( � ) � ADDRESS ,` / I certify that in the performance of the work for which this per- SINK CITY /� TEL. NOr/ mit is issued, I shall not employ any person in any manner so �. ff/^� as to become subject to the Workers Compensation Laws. DISHWASHER CONTRACTOR Date- Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS em tion,you should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR P Y I P CITY TEL. NO. sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM / OUTLETS A—e J r 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER %.91G�� and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION fect. HOSE BIB' DATE License Number Lic. Class CL FINAL O Contractor Date BY U ❑ ®. I am exempt under Sec. V B.&P.C. for this reason Plan check fee poolH Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant '•:' I hereby affirm that I am exempt from the Contractor's License .".. "'I-'' sC ° Law for the following reason (Section 7031.5, Business and Professions Code): Address _ (Q I, as owner of the property, will do the work and the City Tela No. _ ;R 1F'l structure is not intended or offered for sale(Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued f••�. 1. ;i r (Sec. 3097, Civ. C.). ,r �1�_Is 1– (13UI _. X-1 -1 /LES 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 authoryrei,rentatives 'f this my to enter upon the autd property for i on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Date