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APPLICATION OR PMBING PERMIT
COUNTY OF LOS ANGELES
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DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
MAKE CHECKS PAYABLE TO ADDRESS Z`7L( 11^ Q
HARVEY T. BRANDT, COUNTY ENGINEER
LOCALITY "T t
FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST
CROSS ST 11/�
NUMBER FIXTURE OR ITEM2 @0 FEE /) OWNER batilQ. ick
WATER CLOSET v MAIL
BATH TUB 2 00 �Q [� ADDRESS q$ Z'7 DC,( I► es br.
SHOWER 200 CITY GIS T- TEL. NO.
LAVATORY 2 00 v CONTRACTOR
SINK 2.00 ADDRESS
DISHWASHER 2 00 CITY TEL. NO
CLOTHES WASHER 200 STATE LIC
SWIMMING POOL RECEPTOR 200 LICENSE NO CLASS
DISTRICT NO�GROUPJ ONE CESSED BY
LAWN SPRINKLER SYSTEM 2 pp
-- WATER HEATER
200 INDUSTRIAL
WASTE APPROVAL
GAS SYSTEM - OUTLETS 200 INSPECTION RECORD a
OUTLETS OVER
5 PER SYSTEM •30 v
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Plan check fee See Reverse
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
APPRQVALS DATE INSPECTOR'S SIGNATURE
Plan check applicant UNDERZTWF WORK, 0011
NameI GD I LA�Gk ROUGH PLUMBING
Address 8�. � C( 1n 6 LY. GAS PIPING
City Teen �-� Tel No GAS VENT
HOT WATER HEATER
I HEREBY ACKN WLEDGE THAT HAVE READ -THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING GAS TEST -
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO NOTIFIED
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO
RESIDE IN THE ABOVE DESC IBED RESIDENTIAL PROPERTY. FINAL
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SIGNATURE v
OF PERMITTEE
PERMIT VALIDATION CK. MIO. CASH
PLAN CHECK VALIDATION CK. M 0. CASH
1 3.!5 0 `
V-Q
WORKERS'COMPENSATION DECLARATION- 76A667A
I hereby affirm that I have a, certificate-of consent to self ce 817 (2-SO) APPLICATION FOR P L U M B I ISI G. ,P E R•M I T �•
insure, or a certificate of Workers.Compensation Insurance,or i a'
a cer if d copy thereof( ec 3800,Lab.C.) . l
D� ��emnn7 COUNTY,OF LOSANGELES •, _ BUILDfNG�ANDSAFETY°- -
Policy No. mpany
Certified copy is hereby furmshed. FOR APPLICANT TO FILL IN(PRINT OR TYPE) '1- BUILDING
ADDRESS _
Certified copy>5 filed with the county building inspection NUMBER FIXTURE OR ITEM FE_E
, i
de art a LOCALITY
WATER CLOSET
Dat
epplicant NEAREST
• I BATH TUB CROSS.ST
CERTIFICATE OF EXEMPTION FROM W KERS'
COMPENSATION INSURANCE SHOWER— OWNER, C'
`(This section- need not be completed if the work involved LAVATORY MAI
- " ADDRESS-
by the permit is, for one hundred dollars'($100) or less.)
SINK CITY.`T �3 TEL NO O
I certify that in the performance of the work for which this 'DISHWASHER �^ U ,
permitis issued,' CONTRACTORI shall not employ any person in any manner y
so as become subject to the Workers' Compensation'Laws CLOTHES WASHER
ADDRESS'• �' O.`
Date Applicant SWIMMING POOL RECEPTOR
0 NOTICE TO:APPL'ICANT• If, after making this Certificate of CITY p TEL NO. 3 W'
Exemption,'you should' become subject to the Workers' L-AWN'•SPRINKL'ER SYSTEM STATE LIC N
' Compensation provisions of the Labor Code, you must-forth- LICENSE NO CLASS Z
'with comply with such provisions or this permit shall be WATER HEATER
deemed,r,evoked GAS SYSTEM OUTLETS U O DISTRICT NO PTWD SED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER t C_� '
I hereby affirm that I am licensed under provisions of Chapter . 5 PER SYSTEM
9-(commencing with Section 7000) of Division 3 of the Busi-. / FINAL
ness and Professions Code, and my license is in full force and f ->C G� u� U DATE VALIDATION.
effect
FINAL �I
License Number5�� Lic Class�/ ) � - BY
Contracto ,ate` ,��[�'j
0 Plan check fee - J
I am exempt from the licensing requirements as I•am a-
hcensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$'
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE 6-0
V`
Lic.or Reg.No Date Plan check applicant `
HOME OWNER'BUILDER DECLARATION Name
I hereby affirm that' I am,exempt from the Contractor's' Address ,
License Law for the following reason (Section'7031 5, Busi- City Tel No.
ness and Professions Code):
I, as-owner of the'property, am exclusively contracting 4,44'5 4 A
with hcensed contractors to construct the project - -
(Section 7044, Business and Professions Code)., - 1
oso 0.0'0 5 ,
CONSTRUCTION LENDING AGENCY2 0 1a=1`65 0
I hereby affirm that there is a construction lending,agency , ,
for' the performance of the work for which this permit is 0,0
-0 1 5 0'5
issue&(Sec. 3097,Civ.'C) -
Lender's Name
. . 0 b 2 1-'-'8 2-
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 SEE REVERSE FOR EXPLANATORY LANGUAGE "
i ordinances and State laws regulating Plumbing, and hereby ,
authorepresentatives of this County to enter upon the
abzove-m n coned pr erty for inspection purposes
ignature of Permitt Date a f