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HomeMy Public PortalAbout5022 CLOVERLY AVE_Plumbing__ II i -817-8-57 APPLICATION FOR PLUMBING PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER I 7 BUILDING AND SAFETY DIVISION ADDRESS ,4_1�� JOHN A. LAMBIE, COUNTY ENGINEER CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY FOR APPLICANT TO FILL IN NEAREST 4CROSS ST. NUMBER FIXTURE OR ITEM . OWNER WATER CLOSET MAIL BATH TUB ADDRESS SHOWER CITY C TEL.NO. LAVATORY CONTRACTOR Gj ' SINK ADDRESS f: DISHWASHER CITY TEL.NO. LAUNDRY TUB CONTRACTOR'S STATE ❑ REGISTRATION NO. COUNTY ❑ P CLOTHES WASHER ._M; Z9, :,... DISTRICT NO GROUP ZONE READY FOR INSPECTION WATER HEATER GAS SYSTEM INDUSTRIAL WASTE APPROVAL Gtj INSPECTION RECORD APPROVALS @ $1.00 PER ITEM DATE INSPECTOR'S SIGNATURE - 1 OR FIXTURE ® UNDER SLAB WORK ROUGH PLUMBING PERMIT S 1 00 i ��y GAS PIPING TOTAL FEE �'/ F+ i- GAS VENT 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION HOT WATER HEATER s" AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING FIXTURES 1 � PLUMBING. I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR " GAS TEST LDESCRIBED SED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF RNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE i, UTILITY CO. NOTIFIED RESIDENTIAL PROPERTY: TUREERM ITTEE ° FINAL ©z VALIDATION ROBERT A. WOOD, SUPERVISING MECHANICAL ENG'R CK. M.0. 5 , IAr' 23 .76u- JUN 3U 5 A 2Q0 WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby, affirm that I have a certificate of consent to self in- 20-0026 DPW 4/87 sure,or a certificate of Workers'Com ensation Insurance,or 76A667A P CE 817(REV. 8/86) 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 q Certified copy is filed with the county building inspection ADDRESS U NUMBER FIXTURE OR ITEM_ LOCALITY /d t department. @ FEE � L WATER CLOSET(TOILET) Date Applicant NEAREST ' CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. L,> COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100) or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so CITY TEL. NO. as to beco �ICANT: " he Workers'Compensation Laws. DISHWASHER «-- CONTRACTOR , / Date' pplicant CLOTHES WASHER ADDRESS NOTICE O , after making this rtificate of Ex SWIMMING POOL RECEPTOR emption, you should become subject to the orkers'Compen- CITYfl e TEL. IN sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM &AaW A I' ly with such provisions or this permit shall be deemed revok- STATEUC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION fete. DATE 0 ' License Number 4LzJ�ic. Class y f r ( FINAL tZ Contractor ate BY O ElI am exempt un r Sec. v0y B.BP.C. for this reason , g Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION PP I hereby affirm that I am exempt from the Contractor's License Name �. Ar. s Law for the following reason (Section 7031.5, Business and s?+.::; .v Professions Code): Address —+,- I, as owner of the property, will do the work and the City Tel. No. } T structure is not intended or offered for sale(Section 7044, I 1 i= ' Business and Professions Code). , I•i 3 r'L „0 a 50$ CONSTRUCTION LENDING AGENCY �• _ ; .,slob l I hereby affirm that there is a construction lending agency for I�ss the performance of the work for which this permit is issued ?:H,446•.3E `sId (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 above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P ittee 0 Dae 1 WORKERS' COMPENSATION DECLARATION 2DPW 4/87 APPLICATION FOR PLUMBING PERMIT •; Ire"reby,'bffirm that.I have a certificate of consent to self in- 76A6676A667A sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) certified copy thereof (Sec. 3800, Lab. C.) . `fl Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING /' Certified copy is filed with the county building inspection ADDRESS ; 2-2C(6 e department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant �: WATER CLOSET(TOILET) ) NEAREST ' CERTIFICATE OF EXEMPTION FROM WORKERS' / BATH TUB CROSS ST. COMPENSATION INSURANCE ` ^C OWNER �C.� / (1 (This section need not be completed if the work involveSHOWER d by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS ��`z D I certify that in the performance of the work for which this per- 2 SINK " mit is issued, I shall not employ any person in any manner so CITY � TEL. NO.� as to become.sub' ct to the Workers'Compensation Laws. 1 J DISHWASHER CONTRACTO Date Applicant CLOTHES WASHER ADDRESS /1� NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR / emption, you should become subject to the Workers'Compen- CITY TEL. NO, cation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCf99ED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS !T ' 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER �: and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALID ION fect. DATE License.Number Lic. Class O U .. FINAL � Contractor Date BY , O" D I am exempt under Sec. z 0 0 Q,6 A LU # 0.0 o 5 �. B.'&P.C. for this reason Plan check fee , Date: PLUMBING PERMIT ISSUING FEE$ 16 I - 46;50 Signature ° ° x 4 6 5 0 5 TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant 0628, 88 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, as owner of the property, will do the work and the City Tel. No. 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 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 rinspection pur oses. - • SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permi e D to T