HomeMy Public PortalAbout9334 DAINES DR_Plumbing__ 76A667-CES17 6-60
APPLICATION FOR PLUMBIN PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING i" r~� - J-)4 _„
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS ` I 'x "1 � Z F t, " ,i Jam'.
WILLIAM A. JENSEN. SUPT OF BUILDING LOCALITY i
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FOR APPLICANT TO FILL IN NEAREST
EARCROSS sT.
NUMBER FIXTURE OR ITEM OWNER L = ?
WATER CLOSET IL �{' r
BATH TUB r,
ADDRESS C s -6i AL
'u SHOWER CITY a TEL. NO. c
CONTRACTOR ��" yL
C LAVATORY
{ ADDRESS Lly "
SINS
DISHWASHER CITY(-,el, t ) l j` TEL. NO.r .�- o6 r
CONTRACTOR S / STATE f
LAUNDRY TUB REGISTRATION NO. �I O COUNTY
I CLOTHES WASHER DISTRICT N'0 GRO Z NE PR CESS Y
WATER HEATER Q /
GAS SYSTEM INDUST IAL
WASTE APPROVAL,
INSPECTION RECORD / ,>
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01 $1.00 PER ITEM
OR FIXTURE $ I APPROVALS DATE INSPECT 'S SIGNATURE
PERMIT $ 00 UNDER SLAB WORK v-4" ifE� TOTAL FEE ��2
I ,. ROUGH PLUMBING o�A.��./ ?r !l.J-•,r�:l /.✓
- Z GAS PIPING .f
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 'i .GAS VENT
AND STATE THAT THE ABOVE IS CORRECT.AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. HOT WATER HEATER 1
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1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED[.AND/OR : PLUMBING FIXTURES
CE
LINSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE a
DESCRIBED RESIDENTIA PROPERTY UTILITY CO.NOTIFIED
F.
SIGNATURE
OF PERM TTEE 9 d Y + � I"i
= FINAL
®a VALIDATION ROBERT A. WOOD,
Z.0. CASH SUPERVISING MECHANICAL ENG'R
OCT
WORKERS'.COMPENSATION DECLARATIONAi(—IPUCAMN FOR PLUMBING FERMOT
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure,t,r a certificate of Workers' Compensation Insurance, 76A667A"
or a 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 ?
ADDRESS
Certified copy is'filed with the county.building inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY f
WATER CLOSET
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. l�Ae,
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed If the work involved.by MAIL
the permit is for one hundred dollars ($100)or leas.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued,1 shall not employ any person in any manner SINK CITY TEL. NO. r1
so as to becorire,subject to the Workers'Compensation Laws. DISHWASHER !l
CONTRACTOR.
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
Exemption, -you should become"subject,'to' the Workers' SWIMMING POOL RECEPTOR
-Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL. NO.
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9. GAS SYSTEM OUTLETS Q
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and m' license is in full,force and effect. 5 PER SYSTEM'
y FINAL VALIDATION'
License Number Lic. DATEjty,Class U.
FINAL
Contractor Date BY
❑ I am exempt under Sec. 0,
B.&P.C:for this reason 0.1
Plari check fee in
Z
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEEp �Q ,
Plan check applicant
SINGLE,FAMILY
HOME OWNER-BUILDER DECLARATION Name U
I hereby affirm that I am exempff ram the Contractor's License if' E
Address
Law for the following reason (Section 7031.5, Business and ._
Professions Code): k City .., Tel. No W s
1, as owner of the property, will do the work and the s [
structure is not intended or.offered for sale (Section pE ) �— Y�
7044, Business and Professions Code). " ' �` "`"'—
CONSTRUCTION LENDING AGENCY CIr
1 hereby affirm that there is.a construction lending agency for e•I lHit_
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name EJ1 _ .fl_'li _>'.vls+.,f
Lender's Address $_t_I _ A
I certify that I have read'this application and state that the
above information is correct. I agree to comply with all County D
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 Permittee , Date