HomeMy Public PortalAbout6023 CLOVERLY AVE_Plumbing__ 76AS67 APPLICATION FOR PLUMBING PERMIT ,
DBS-17
DIVISION OF BUILDING AND SAFETY
Department of County Engineer
County of Los Angeles ABUILDI s ®�� a�
JOHN A. LAMBIE, COUNTY ENGINEER
CASSATT D. GRIFFIN,SUPT OF BUILDING
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
OWNER z eZi DISTRICT NO. GROUP I READY FOR INSPECTION
MAIL
ADDRESS
a INDUSTRIAL
CITY TEL. N WASTE APPROVAL
PLUMBEc,��`" INSPECTION RECORD
ADDRES
CIT L%STEL. N
LICE N of -
NUMBER TYPE OF FIXTURE OR ITEM FEE '
WATER CLOSET (TOILET) @ $I.00 $
BATH TUB @ $1.00
SHOWER @ $1.00
LAVATORY (WASH BASIN) @ $1.00
KITCHEN SINK @ $1.00
DISHWASHER @ $1.00
LAUNDRY TUB OR TRAY @ $1.00
CLOTHES WASHER @ $1.00
WATER HEATER @ $1.00
GAS SYSTEM @ $1.00
T APPROVALS
DATE INSPECTOR'S SIGNATURE
UNDER SLAB WORK
PERMIT $ 1 00 ROUGH PLUMBING
9GAS PIPING
TOTAL FEE '90
GAS VENT
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION HOT WATER HEATER
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. PLUMBING FIXTURES '
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR GAS TEST
LICENSED AS REQUIRED L GAL COUNTY AND STATE OF
CALIFORNIA OR THAT AM E LEGAL OWNER OF THE ABOVE UTILITY CO. NOTIFIED
DESCRIBED RESIDENTI P PERTY.
SIGNATURE
OF PERMIT' EE FINAL V Z
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERTA.WOOD, CHIEF PLBG. INSPECTOR
CK. M.0, CASH
o5 5 8 g n mAY 1 3 2.0 0 m
WORKERS COMPENSATION DECLARATION Y
-.e 200026DPW4/87 APPLICATION FOR PLUMBING PERMITt� '
I hereby affirm that I have a,cerhficate of consent to self in 76A667A _ t 1
su-G; or a certificate,of Workers Compensation I�surance or a CE 817(REV 8%86) a
certified gopy thereof (Sec 3800, Lab ) - 4
- _ COUNTY OF LOS ANGELES' DEPT 'OF PUBLIC WORKS
Policy No Company "
Certified copy is, ereby furnished _ h
FOR APPLICANT TO FILL IN (PRINT,OR TYPE) BUILDING` ° ?
❑ Certified cop`y'is filedwith the county`building inspectionADDRESS
department s 1 7 c^ — NUMBER z.FIXTURE ORhEM_ @' FEE LOCALITY
V 'J , >
DateAppl
' icant '� WATER CLOSET,(TOILET) > RTI NEAREST
1 BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS
J COMPENSATION INSURANCE , e - OWNER` �•
>F SHOWER �1
(This section need ri6t be completed if the'work involved by O MAIL e °
<J„t t_he permit Js for one hundred dollars (5100) or less ) LAVATORY r ZP4 ��ADDRESSI certifytthat in the performance of the work for which this per- SINK mit is issued I shall°not°employ any person in any manner so 'r -- ; O Y TEL'NO
CONTRAC
as'to'become subject-to the Workers Comp '1 DISHWASHER c r 1
TOR
Date'- P Applicant CLOTHES WASHER
ADDRESS,
NOTICE
NOTICE TO APPLICANT If "after making thi's'Certificate of Ex- SWIMMING POOL RECEPTOR
emptio{ you should become sublect totheWorker's Compen r CITY TEL NO P' > ° ✓
sation provisions of'tlie Labor Code youfrriust forthwith°comp- LAWN SPRINKLER SYSTEM' `
ly'with'such provisions or this permit shall be deemed revok STATE LIC
ed - I " °,( _ I ' � � t . -i'• °-WATER HEATER O LICENSE NO GLASS
"LICENSED CONTRACTORS DECLARATION DISTRICT NO PRO ED
lierBY
reby�affirm'that I amlicensed under,provisions of Chapter t GAS SYSTEM OUTLETS r
'I
9(commencing with Section 7000)of Division 3 of the Business a OUTLETS OVER f' '
Is' _5 PER SYSTEM °
and Professions Code and my,hcense is-in full force and ef- _ _ FINAL • VALI ATION
fect DATE d
Q _'!� v -
License�Num er' v �S LicClass b u F s U
r
FINAL
„- ., BY
Contractor , `' ate _ 0
,
❑ e -
I am exempt under Sec W
CL
" B'&P C forxthis reason Y
4 Plan checktfee
► r
Dote^ ` g' PLUMBING'PERMIT ISSUING FEE $
Si nature' - r
g TOTAL FEE H
-
SINGLE FAMILY '< , "r ' J, `
applicant
'HOME OWNER BUILDER DECLARATION Plan check a I I " 4 1 a ' 3307 ;114o.c5cR
I hereby offir"m that I am exempt from the Contractor s'License Name r e, e v
Law for the following reason (Section 7031 5 Business and 1 ITEMS `
Professions Code) > Address
, 3 - - - . TIaTAL 118®56
1,-as owner orf the property will do the work and the C tY Tel No - _ ,
�>
structure is not intended or offered for sale(Section 7044 r a S, Y P , t „CHECK ° 11�
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 thisis issued d
' r` tk °
P ,. ,� , , � � 0I�O'Cl�O1 11/1,3r`t
(Sec 3097 Civ C ) - a w 4
67,52 2 1 AMICI°1-
Lender�s Name
' Lenders Address y _
I certify that I have read this application land state that the
" above�information'is correct 1 agree to comply with all County a
ordinances and State ws regulatmg_Plumbing, and hereby
authorize representa ves of"this County to enter upon the
above- tioned p perty for inspection purpose _ _ r
SEE REVERSE FOR EXPLANATORY LANGUAGE =
Signature of Permittee Dat r
c
E r