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Home My Public Portal About5010 CLOVERLY AVE_Plumbing__ 46A667-CE81712/59 TEMPLE CITY s - APPLICATION FOR PLUMBING PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER r BUILDING VBDIE, AFETY RIVISION BUILDING i"Q`9 GLav` �r JOHN A LA BI COUNTY NGINEER ADDRESS WILLIAM A JENSEN SUPT OF BUILDING r►� N LOCALITY FOR APPLICANT TO FILL IN NEAREST Q CROSS ST NUMBER FIXTURE OR ITEM OWNER WATER CLOSET MAIL BATH TUB ADDRESS CITY NO / /J SHOWER � CONTRACTOR ® LAVATORY =�'/p SINK ADDRESS DISHWASHER CITY TEL NO CONTRACTOR S STATE ElLAUNDRY TUB REGISTRATION NO COUNTY ElCLOTHES WASHER DIST ICT� P ZONE PR ES SED BY WATER HEATER GG GAS SYSTEM INDUSTRIAL WASTE APPROVAL INSPECTION RECORD y ,/ % O F U W a rn ® $1 00 PER ITEM OR FIXTURE $ APPROVALS DATE INSPECTOR S SIGNATURE PERMIT $ I �00 UNDER SLAB WORK ~7 �. TOTAL FEE ROUGH PLUMBING l 6-H dia nlZt , r GAS PIPING 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION GAS VENT AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY LDESCWITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER RIBED CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES S REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST -- OR THAT I AM THE LEGAL OWNER OF THE ABOVE RESIDENTI OPERTY UTILITY CO NOTIFIEDITTE FINAL ev VALIDATIOI�� ROBERT A WOOD, P CK b O ( esH SUPERVISING MECHANICAL ENG R �tlr 0 4 1 1 9 Z8 r4htt 2 C) 5 D 5 00 �; 76AS67 17 11-5o APPLICATION FOR PERMIT DEPARTMENT OF BUILDING AND SAFETY COUNTY OF LOS ANGELES ` WILLIAM J. FOX, CHIEF ENOINEER DISTRICT P O E1 FOR APPLICANT/STD FILL IN �� q_ V( J PLUMBER (� RE IVED BY READY FOR /DATE ISSUED FIRST INSPECTION ADDRESS & BUILDING D/D ,/�� r� CITY TEL. No ADDRESS �/� V/�C' COUNTY LOCALITY Z/Pr `�+ C-/7 LICENSE NO EXPIRES NEAREST PERMIT FEES CROSS ST}/. M6►,��'//� /1 Q/��'/��J�( /�(/1 //�� NUMBER TYPE OF FIXTURE OR ITEM FEE OWNER i /!/ ��I"�'r•► •• • I�•' MAIL- ® WATER CLOSET(TOILET) O 50 ffi ADDRESS BATH TUB @ 050 CITY /T. TEL No SHOWER @ Oso I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS LAVATORY (WASH BASIN) O 50 APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES KITCHEN SINK @ 050 AND STATE LAWS REGULATING PLUMBING . F CERTIFY THAT I POSSESS THE ABOVE VALID LOS LAUNDRY TUB OR TRAY @ O 50 ANG ELEWYCOUNTY LICENS€, OR I AM THE&lEGAL OWNER OF THE RESIDENTIAL PROPERTY DESCRIBErDD ABOVE. GAS SYSTEM OUTLETS @ O 51) F.fpe _ 1` � SIGNATURE OF (t!"'�r,j/(f It WATER HEATER @ O 50 PERMITTER SLOP SINK @ D 513 INSPECTION RECORDf FLOOR SINK 0 0.50 ✓ FLOOR DRAIN @ O 50 a - z S -S DISHWASHER @ Oso DRINKING FOUNTAIN @ 050 /�'��"� URINAL C� 0 50 C—'i'� CsV�^t Gam 'c r+i L .Z°t L+ie+''7•"/'� Q HOUSE SEWER @ 050 ,4=a7� MISCELLANEOUS o C.7G-q5 457- a APPROVALS DATE INSPECTOR'S NAME ROUGH PLUMBING i A OAS PIPING GAS VENT CESSPOOL @ IDD CESSPOOL SEPTIC TANK SEPTIC TANK DRAIN ( ) PIT ( ) @ 1 0131 SEWER PERMIT I 1 DD GAS TEST "" UTILITY CO NOTIFIED TOTAL FEE S D FINAL '��- WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 'fl I hereby affirm that I have a certificate of consent to self 76A667A ,rin.wre,:or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) riff' d cop th�e9reof (Sec. 3800, ab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Ycy N Y// Company Fje d.,J ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING / A,, ` c�/Q ,Ve�` J Certified copy is filed with the county building ins ec- ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET Date?—OL & Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER �S (This section need not be completed if the work involved by MAIL n the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS Q a l (O tj wH'2_ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. _ so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER N / ('c /V. NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL. NO. tr Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM ��- with comply with such provisions or this permit shall be STATE7 LIC. deemed revoked. WATER HEATER LICENSE NO. U,j ASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY OUTLETS O I hereby affirm that I am licensed under provisions of Chapter 9 � GAS SYSTEM � Q (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINALVALIDATIO DATE ✓� a License Number�_10 7 35 Lic. Class e Ye Contractor �ON�d2 Date L (' BYAL Q. ❑ I am exempt under Sec. 0 U B.&P.C. for this reason LLI Plan check fee N Date: PLUMBING PERMIT ISSUING FEE$ Signature Z 4 .54 ;95524A - TOTAL FEE �p 0 # 0 0 0 0 0 5 Plan check applicant # 0 0 0 0 0 5 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name ( a o 1 6 5 0 1 hereby affirm that I am exempt from the Contractor's License Address o 0 0 1 5 0 Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. 0 9.29-86 ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section Opp. 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 (Sec. 3097, Civ. C.). 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 upon the obove-mentioned property for inspection purposes. /)A SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date