HomeMy Public PortalAbout5428 CLOVERLY AVE_Plumbing__ 76A667-CE817 6-60
APPLICATI N FOR PL MEBING PERMIT �
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING L /�
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
WILLIAM A JENSEN SUPT OF BUILDING
" LOCALITY ,
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FOR APPLICANT TO FILL IN NEAREST
CROSS ST
NUMBER FIXTURE OR ITEM
OWNER
WATER CLOSET MAIL
HATH TUB ADDRESS
CITY TEL NO
" SHOWER
CONTRACTOR
LAVATORY
Suis ADDRESS
n)
DISHWASHER CITY U TEL NO. VO
CONTRACTOR S _ n STATE
COUNTY
LAUNDRY TUB REGISTRATION NO c�
CLOTHES WASHER DISTRICT N GRO ZONE E D BY
1 WATER HEATER r D44
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL
INSPECTION RECORD
N
P.
O
V
o
N
Ul
P.
7-—11t-S P/1001-- i
® OR IPER RE
APPROVALS DATE INSPECTOR S SIGNATURE
PERMIT $ 2 00 UNDER SLAB WORK� '2/-6
TOTAL FEE ROUGH PLUMBING rO
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
LCALIFORNIA
ING
REBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES .a
ED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
OR THAT AM TIR�IE LEGAL OWNER OF THE ABOVE
BED RESIDENTIA PROPBRTY UTILITY CO NOTIFIED
TURE (( n� e
ERMITTE FINAL
Or VALIDATION ROBERT A WOOD.
� y p ri=g SUPERVISING MECHANICAL ENCi'R
�, �c 4 1 4 2 lAi rj 5 D900
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
J'hereby,-taff rm that I have a certificate of consent to self 78A887A t
insure, or a�i� rtificate of Workers' Compensation Insurance, CE 817(REV 8/88)
or a`certified copy thereof (Sec 3800, Lab C )
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No Company I I _ '
Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ADDRESS Aix '
Certified copy is filed with the county building inspec-
tion department NUMBER FIXTURE OR ITEM ® FEE LOCALITY
WATER CLOSET '
Date Appli4ant NEAREST r ,
CERTIFICATE OF EXEMPTION FROM WORKERS
BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OT OWNER OZ
(This section need not be completed if the work Involved by
MAIL '
the permit is for one hundred dollars ($100)or less') LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY TEL NO
so as to become subject to the Workers'Compensation Laws DISHWASHER
CONTRALTO '
Date Applicant CLOTHES WASHER ADDRESS 6`
NOTICE TO APPLICANT If after making this Certificate of
Exemption, you should become subject to'the Workers' SWIMMING POOL RECEPTOR CITY L NO
Compensation provisions of the Labor Code, you'must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit 'shall be STATE LIC
deemed revoked n r WATER HEATER LICENSE NO CLASS G
LICENSED CONTRACTORS DECLARATION DISTRICT NO PR9CESS6D BY
I hereby affirm that I am licensed'under provisions of Chapter 9 - GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ) `6 a
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL ' 691 VAL ATION O
License Number Lic Class c Ir
F 0
Contractor ` 1' Date U
❑ LLT
I am exempt under Sec � d
B 8P C for this reason ;2825.1 A a
Plan check fee
# 000005
Dat PLUMBING PERMIT ISSUING FEE$
I o,o'S>3�50
Signature TOTAL FEE o o o 5 a 5,0 c=i
t
�+ Plan check applicant - ,I A 0 2"8 7'
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATIONt Name _
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031 5, Business and-
Professions Code) I City Tel No
❑ I as owner of the property, will do the work and the ,
structure is not intended or offered for sale (Section polo h
7044, Business and Professions Code)
i
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 a
,
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
abo menti ed property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si azure of Permittee ` Dbte