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Home My Public Portal About5338 CLOVERLY AVE_Plumbing__ 76A667-CE817 12/59 APPLICATION FOR PLUMBING PERMIT , COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING �ANNDD S�gTY RIVISION BUILDING ' JOHN A LAMBIE COUNTY ENGINEER ADDRESS G� l"I Li WILLIAM A JENSEN SUP T OF BUILDING t - LOCALITY yL FOR APPLICANT TO FILL IN NEAREST CROSS ST NUMBER FIXTURE OR ITEM OWNER WATER CLOSET blAIL ADDRESS BATH TUB CITY TEL NO SHOWER f/ LAVATORY CONTRACTOR l p e Q '! ADDRESS A SINS DISHWASHER CITY fp TEL NOJ29 CONTRACTOR S -y STATE LAUNDRY TUB REGISTRATION NO ,7 COUNTY ❑ CLOTHES WASHER DISTRICT NO GROUP I ZQNIE 1 %R ESSED BY WATER HEATER :5n,7 1 J1. GAS SYSTEM INDUSTRIAL WASTE APPROVAL p d INSPECTION RECORD P. pci0 O F W a� 0 00 PER ITEM O $ ,� OR FIXTURE gppR VALS DATE INSP CTOR S SIGNATURE PERMIT $ 2100 UNDER S7•AC3'WORK AjA� a/ TOTAL FEE ROUGH PLUMBING GAS PIPING 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER PLUMBING 1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES / LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST d IJ CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL OPERTY TILITY CO NOTIFIED A SIGNATURE 44 OF PERMITTE FINAL ®r gALIDATION ROBERT A WOOD, Id 0 CASH SUPERVISING MECHANICAL ENG R 4 4 a 1 -�08 2 7 5 D 18 .0 0 —Af"' asp/ L • 1 I i WORKER S COMPENSATION DECLARATION - 20-0026 DPW 9/89 76A667A APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self insure I , or•a certificate of Worker s Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV P li No Company z=��/ ar i Certified copy is hereby furnished ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING'I ADDRESS Certified copy is filed with the co ty bu g inspection dep ent NUMBER FIXTURE OR ITEM ® FEE LOCALITY Date pplicant WATER CLOSET 5 NEAREST CE KATE OFiEXEMPTION F WORKERS BATH TUB C CROSS ST COMPENSATION INSU ANCE •7 ASSESSOR ` SHOWER MAP BOOK PAGE P RCEL (This section need not be completed if the work involved by the permit is for one hundred dollars($100)or less) LAVATORY p� OWNER I certify that in the performance of the work for which this permit (/ iMAIL s issued I shall not employ any person in any manner so as to SINK ADDRESS become subject to the Workers Compensation Laws n � O Z— DISWASHER \ CITY EL NO Date Applicant CLOTHES WASHER NOTICE TO APPLICANT If after making this,Certificate of CONTRACTOR Exemption you should become subject)to the Workers Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL NO L I hereby affirm that I am licensed under provisions,of Chapter 9 WATER HEATER v^ d (commencing with Section 7000) of Division 3 of the Business and STATE 1 LIC GAS SYSTEM OUTLETS LICENSE NO CLASS 0 0 Professions Code and my license is in full force and effect - OUTLETS OVER .DIST C OCEWD BY cr 5 PER SYSTEM (�f( 0 License Number Lic Class V FINAL DATE /8_ 9/ ALIDATION a Contractor Date f) F ❑ I am exempt under Sec BY AL `l I Z B&P C for this reason o Plan check fee 1 Date Poo- Signature Signature t PLUMBING PERMIT ISSUING FEE$ , ❑ TOTAL FEE \ ' Plan check appllcant - SINGLE FAMILY 1 HOME OWNER BUILDER DECLARATION Name Af T ag I hereby affirm that I am exempt from the Contractors License'Law — t 00 for the following reason (Section 7031 5 Business and Professions Address ��0 -tJe Code) i ITEM F-1 City Tel No I as owner of the property will do the work and the structure U is not intended or offered for sale (Section 7044 Business TOTAL - and Professions Code) (HECK 4.CID n CONSTRUCTION LENDING AGENCYt ti Hth�UE n(II3 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) i Lender s Namer�t-+r t� Lender s Addre I certify that Ih e ion and state that the above , information is corre t 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 ' � r WORKERS COMPENSATION DECLARATION M APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a cert-ficate of consent to self 76A667A sure, pr a certificate of Workers Compensation Insurance CE 817(REV 10/81) a certified copy thereof(SSec 3800, ab C ) p COUNTY OF'LOS ANGELES %BUILDING AND SAFETY Policy No So 6gpan LF�N'[ I L I ID ified copy is hereby furnished FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING � � / Certified copy is filed with the county build n e - ADDRESS tion department NUMBER FIXTURE OR ITEM FEE r LOCALITY ^ � � Date Z� —J Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM 44KERS BATH TUB CROSS ST c COMPENSATION INSURANCE SHOWER OWNER �S (This section need not be completed if the work involved by the permit is for one hundred dollars (;100)or less ) LAVATORY MAIL ADDRESS lo vei- 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 CITYTEL NO L r so as to become subject to the Workers'Compensation Laws DISHWASHER v f CONTRACTORY f^ G sl OO Date Applicant CLOTHES WASHER & r /� NOTICE TO APPLICANT If, after making this Certificate of ADDRESS RECEPTOR OR Exemption you should become subject to the Workers SWIMMING POOL 1 Compensation provisions of the Labor Code, you must forth- CITY r TEL NO LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATELIC deemed revoked WATER HEATER LICENSE NO CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO ESF I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM / OUTLETS (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 FINAL /� DATE VAL ATION u / License Number,/j[ �v `p� Lic Class �_�/ Im V O � FINAL 0 Contractor I/ Ylp Date 42-_5 `^, BY f ❑ I am exempt under Sec t B &P C for this reason 1 6 U Plan check fee ` Date PLUMBING PERMIT ISSUING FEE$ Signature ' TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name o6a r I hereby affirm that 1 am exempt from the Contractor's License Address l�/ h ar 7 3 �!, 1 tP, Low for the following reason (Section 7031 5, Business and S Professions Code) City " �� ` Tel No 3 —2_jD0 # 0 0 0 0'0 5 ❑ I as owner of the property, will do the work and the 2 or o 1650 structure is not intended or offered for sale (Section , 7044 Business and Professions Code) 1 6 5 0 `oto 0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for 1205-83 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 hove 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 move-mentioned prop ty r ins ectton purposes , [-'/'/ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of rmtttee Date