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HomeMy Public PortalAbout5017 CLOVERLY AVE_Plumbing__ - / 78A887•CE# ITT 081 7 10.82 APPLICATION FOR PLUMBING PERMIT COUNTY OF, LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISIONBUILDING f JOHN A LAMBIE,'COUNTY ENGINEER ADDRESS Cr WILLIAM A JENSEN, SUP T OF BUILDING LOCALITY ' s FOR APPLICANT TO FILL IN NEAREST 4 CROSS ST. j-tE Q NUMBER FIXTURE OR ITEM EACH FEE OWNER WATER CLOSET $1 25 MAIL BATH TUB 1 25 ADDRESS PC/ arfec/l) SHOWER 125 CITY TEL NO.A LAVATORY 125 Y-6-7 CONTRACTOR SINE 1 25 — ADDRESS , DISHWASHER 1 25CITY L TEL NO U 6 LAUNDRY TUB 1 25 CONTRAC OR'S STATE le REGISTRATION NO �� D 'COUNTY [] CLOTHES WASHER 1 25 DISTRICT NO GROUP ` ZONE ROCESSED BY, - WATER HEATER _ 150 150 INDUSTRIAL GAS SYSTEM OUTLETS Q O -- WASTE APPROVAL OUTLETS OVER 5 PER SYSTEM 30 � INSPECTION RECORD V A/?,9/4 ` Y��' ��� ������ o U Lu r APPROVALS DATE, INS:PEEC{TOOR-S SIGNAT PERMIT $ 2 00 UNDER SLAB WORK ROUGH PLUMBING TOTAL FEE1.) GAS PIPING I HEREBY ACKNOWLEDGE THAT 1 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 HOT WATER HEATER PLUMBING F e f I HEREBY CERTIFY--THAT' I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES (� LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE SOF GAS TEST ! 4, CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF,AND INTEND TO RESIDE IN,THE ABOVE'�E�CRIBED RESIDENTIAL PROPERTY UTILITY CO NOTIFIED SIGNATURE (/J w �J OF PERMITT E 1 FINAL 6/(i7 ID , VALIDATION ROBERT A rWOOD M O CASH SUPERVISING MECHANICAL ENG R ' Ao4 7 & 4� OCT13 5 0 1 5.0 ON ` )wl WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I herd by, oflirm that I have a certificate of consent to self in- 76A6667A 4/90 surd,ora certificate of Workers'Compensation Insurance,or a r certified copy thereof (Sec 3800, Lab C ) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy��„No. Company Certified copy is hereby furnished ' FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESS department NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST A� -�- COMPENSATION INSURANCE SHOWER OWNER J (This section need not be completed if the work involved by MAIL , the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS \5__©17 I certify that the performance of the work for which this per- 't SINK CITY Z mit is issued,, I shall not employ any person in any manner so TEL NO / as to become sje t to the Workers'Compensation Laws DISHWASHER - _ CONTRACTOR Ulo VIc�� �'7 Date �i Applicant�(l�//��_/lam CLOTHES WASHER ADDRESS y�i ^ NOTICE TO APVICANT If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR - � empt(on,you should become subject to the Workers'Compen- sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEMS CITY P / TEL NO 22 r- M ly with such provisions or this permit shall be deemed revok- STATE ` L ed WATER HEATER LICENSE NO �Ol CLASS !LS LICENSED CONTRACTORS DECLARATION / DISTRICT NO PROCESSED BY 1 hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION fect / HOSE BIB DATE 7 >. License Number / LicClass = a FINAL — V Contractor Ccs U��I 12 pate 2 t BY '-='- _ Q I am exempt under Sec // / I1 -r -t1 U B &P C for this reaso W /� Plan check fee 8 ► a •1 ° Y PLUMBING PERMIT ISSUING FEE$ ; F g Signature / ✓�/— a -' y� TOTAL FEE fLQ I-"�� :L:34 ® 40 L / SINGL FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031 5, Business and Professions Code) Address " i r� •i 0 j, as owner of the property, will do the work and the City Tel No i lad 1!I—_4il�J f f:t�T r 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 - (Sec 3097, Civ C ) Lender's Name Lender's Address I certify that I hav read this application and state that the Poo.above informatio is correct I a ree to comply with all County ordinanc n tate laws gula ing Plumbing, and hereby outhonz � resentat ' f th,VCounty to enlpr upon the abo e- boned rt y or rt!ispection p7urpes 2 l!/ SEE REVERSE FOR EXPLANATORY LANGUAGE e Sig °lure of ermittee-' Dat