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APPLICATION FOR PLUMBING PERMIT
1
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
ADDRESS
NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
WATER CLOSET
NEAREST
BATH TUB CROSS ST
SHOWER OWNER
LAVATORY MAIL
ADDRESS
SINK CITY TEL NO,—
DISHWASHER CONTRACTOR
CLOTHES WASHER ADDRESS /
SWIMMING POOL RECEPTOR
CITY TEL NO _ D
LAWN SPRINKLER SYSTEM STATE LIC
WATER HEATER LICENSE NO —15?J CLASS
GAS SYSTEM OUTLETS APPROVALS DATE INSPECTOR S SIGNATURE
OUTLETS OVER UNDER SLAB WORK
5 PER SYSTEM ROUGH PLUMBING
GAS PIPING
GAS VENT %)
HOT WATER HEATER 0
PLUMBING FIXTURES 699
r' GAS TEST
Plan check fee ^°' ��T .r UTILITY CO NOTIFIED
PLUMBING PERMIT ISSUING FEE$
TOTAL FEE o FINAL �Lf! 0�/Z/��fll�/
Plan check applicant PLAN
pCHECK
�jVALIDATION
Name
Ili ►� �"' p7� �� /i )7 PH Dell's
Address 11 !�
City Tel No
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES 000 C6 iiiJJJ
AND STATE LAWS REGULATING PLUMBING PERMIT VALIDATION
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS
REQUIRED BY LOS ANGELES CALIFORNIA OR THAT I AM THE
L GAL OWNER OF AND ND TO RESIDE THE A OVE DESCRIBED RESIDENTIAL
PROPE
-s,G,N ATU '- -a-7
OF PERMITTEE
D ISTRICT IyQ R CESSED BY
UY
INDUSTRIAL
WASTE APPROVAL
1
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in-
76AA66DPW 4/90
suet,or a certificate of Workers Compensation Insurance'or a
certified copy thereof (Se 3800 Lab C )
� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No r 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
depar ment NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date J(L —�
/ �� Applicant ,1 WATER CLOSET(TOILET)
� f�IY,� \'f•—�./ CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB
COMPENSATION INSURANCE SHOWER b OWNER 4
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less ) LAVATORY ADDRESS
1 certify that in the performance of the work for which this per- SINK CITY TEL N
mit is issued, I shall not employ any person in any manner so
as to become subject to the Workers'Compensation Laws DISHWASHER
CONTRACTOR �
Date. Applicant CLOTHES WASHER �Q �Ry`
NOTICE TO APPLICANT If, after making this Certificate of Ex- ADDRESS
emption,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR CITY TEL NO c
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEMS
Iy with such provisions or this permit shall be deemed revok- STATELIC
a( �n `� •ZC,
ed WATER HEATER LICENSE NO 2CLASS
LICENSED CONTRACTORS DECLARATION / DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER ✓ O
and Professions Code and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect HOSE BIB DATE � + a
License Number v7 Lic Class P� p
y ff GIjI BY FINAL c
Contractor11A`� l:)J DateA cc
ACCT.tr
I am exempt under Sec
M-
3s0 3 44.10 W
B &P C for this reason0 1 ITEMS tCL
o
Plan check fee
t Date PLUMBING PERMIT ISSUING FEE$ Z
Signature TOTAL FEE TOTAL 44 - 10
SINGLE FAMILY CHECK 44.10
HOME OWNER-BUILDER DECLARATION Plan check applicant CHANGE °00
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
O000-Oao 1 7/15/96
❑ 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, 7436 1 ACM"??
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
abWe-a boned Apefor inspection jWR� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of rmittee Date