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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS 1p% L A = �Z
JOHN A. LAMBIE, COUNTY ENGINEER
WILLIAM A. JENSEN, SUPT OF BUILDING
LOCALITY -�-� C,
FOR APPLICANT TO FILL IN NEARECAOSSSST. V
UC-
NUMBER
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NUMBER FIXTURE OR ITEM EACH FEE r.
OWNER �=. �� ��, 1 C
WATER CLOSET $1.25
BATH TUB 1.25 ADDRESS C, gy h
SHOWER 1.25 CITY 'r(zN4 IZ TEL. NO.PL
LAVATORY 1.25 CONTRACTOR
SINK 1.25 ADDRESS C)q-t_� G N U
DISHWASHER 1.25 CITYNAV-QZ I-T TEL. NO. 4'4 L-1 J'?o
LAUNDRY TUB 1.25 CONTRACTOR'S STATE 8
REGISTRATION NO. LI R COUNTY ❑
CLOTHES WASHER 1.25 DISTRICT NOQ. � GR P ZONE I P OCES Y
' WATER HEATER 1.50
1 WASTE APPROVAL
50 INDUSTRIAL
GAS SYSTEM OUTLETS rL
O
OUTLETS OVER 5 PER SYSTEM 30 INSPECTION,RECORD r ] V
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APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT 5 2 00 UNDER SLAB WORK
3 sv ROUGH PLUMBING
TOTAL FEE
GAS PIPING
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER
PLUMBING.
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF,AND INTEND TO
RESIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. UTILITY CO. NOTIFIED S
SIGNATUREZz
QA
OF PERMITTEE "`✓V✓✓-w��-� FINAL
ALIDATION ROBERT A. WOOD
cK. M.O. CASH SUPERVISING MECHANICAL ENG'R
HALO 8 5 5-0 JMJ 18 5 D3.5 J- rki
WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
• I hereby affirm that I have a certificate of consent to self 76A667A
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished.copy BUILDING
F-1FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified cois filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET /T
Date Applicant NEAREST /
CERTIFICATE OF EXEMPTION FROM WORKERS' r BATH TUB CROSS ST. �L � G
COMPENSATION INSURANCE SHOWER OWNERj �
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS t'
I certify that in the performance of the work for which this ,
is issued, I shall not em to an erson in a m ner SINK CITY TEL. NZrmit
P Y Y P y rhi/%LF fT as to become subject to the Workers'C pe t' Laws. DISHWASHER
CONTRACTOR
Date �� Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after .king this Certificate of ADDRESS
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL. 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. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTUQT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS I �t ��
(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 P �/ ` VALIDATION
DATE l (i l U
License Number Lic. Class 129
FINAL
Contractor Date BY
❑ _
I am exempt under Sec. $A
B.&P.C. for this reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY ._
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
ri,
sions Code): CityTel. No.
as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, 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
above-me boned pr perty for In coon purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
i� 01
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So P rmittee Date