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APPLICATION FOR PLUMBI G PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONAssT.
SS 21 Degas Ave.
BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER
WILLIAM A. JENSEN. SUPT OF BUILDING
ITY Temple Cit
FOR APPLICANT TO FILL IN gndwiCk
NUMBER FIXTURE OR ITEM EACH FEWATER CLOSET §I,45R Dnal Corp.
MAIL
1 BATH TUB 1,25 1 25
ADDRESS
1 SHOWER 1.25 1.25 CITY TEL. NO.
0 LAVATORY 1.25 CONTRACTOROwen Bros- Plumbing,
1 SINK 1,25 1.25 ADDRESS 4265 No. Baldwin Ave,
1 DISHWASHER 1.25 1.25 CITY El Mont TEL. NO' 443-
CONTRACTOR'S STATE
LAUNDRY TUB 1.25 REGISTRATION NO. 231741 COUNTY p
1 CLOTHES WASHER 1.25 1 25 DISTRICT NO. GROUP ZONE RO EBBED BY
1 WATER HEATER 1.50 1.50 5 k op
1 5 1.50 1.50 INDUSTRIAL ' Ly
CAS SYSTEM OUTLETS WASTE APPROVAL
OUTLETS OVER 5 PER SYSTEM .30 --Z;�� INSPECTION RECORD V
Se 1 L �. I N Es 'fOU STE ±9 O f` O
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APPROVALS DATEINSPECTOR'S SIGNnTURE
PERMIT S 2 00 UNDER SLAB WORK _
ROUGH PLUMBING -S�
TOTAL FEE
1 16-69 GAB PIPING
I NEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATI GAS VENT
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE Y A
WITH ALL COUNTY Ofl OINANCES ANO STATE LAWS REE COMPLY
HOT WATER HEATER
PLUMBING. �L /
1 HEREBY CERTIFY THAT I S PROPERLY REGISTERED AND/OR PLUMBING FIXTURES / '/�
LICENSED AS RE HAT I M LOS ANGELES COUNTY OF. AND STATE OF GAS TEST L drtnyr
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF.AND INTEND TO
RESIDE IN.THE ABOVE SCRIBED RESIDENTIAL PROPERTY. UTILITY CO. NOTIFIED
SIGNATURE
OF PERMITTEE FINAL �I �Icl)tOiLt�'u-
/1(ALIDATION ROBERT A. WdOn
cK. M.D. CASH SUPERVISING MECHANICA/ENG'R
Lr,I:o9347 �Pu,R 8 s o 16.25
RS'COMPENSATION DECLARATION
L I + y a•f4havecertificate consent to self 76A6M7A
APPLICATION FOR PLUMBING PERMIT
insure, or a certificate of Workers' Compensns ation Insurance. CE en(REV. IO/81) V
or'a certified copy thereof (Sec. 3800, Lab. C.) qr COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polic Company Ied
Certified copy is hereby furnis . AL
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ,+ of
ertified copy is filed with the county building inspec- ADDRESS ,y
tion department NUMBER FIXTURE OR ITEM rCU FEE '
/ O^ WATER CLOSET
LOCALITY
Date ^ — ✓ Applicant �w L /fT s'�r NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.,
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work Involved by SHOWER MAIL q .
the permit is for one hundred dollars ($100)or less.) fAVATORV ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. r
so as to become subject to the vers'Com soli Laws. DISHWASHER -7�
CONTRACTO 74�;-
Dat -_::�1 App I ice nt / CLOTHES WASHER
�
� /
NOTI E TO APPLICANT: If, afte ADDRESS
making this Certificate of ry(/
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO,
with comply with such provisions or this permit sholl be LA'W'N SPRINKLER SYSTEM + www
STATE LIC.
deemed revoked. WATER HEATER J LICENSE N _ CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. .i/ ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS Jam(' ivIOY /
(commencing with Section 7000) of Division 3 of the Business OUTLETS VER
and Professions Code,and my license is in full force and effect. 5 PER TE/,sI
U DATE
VAL ATION 0O
License NumberLic. Class QV
n, '/ FIN Q=
�✓ Date BY 0
❑ I am exempt under Sec. 1 8 7.O A d
N
B.BP.C. for this reason # ° ° 0 0 65 z
Plan check fee
Dale: PLUMBING PERMIT ISSUING FEE$ 0 ( ° - 3050
Signature
TOTAL FEE 30 S ? ° . 30503
SINGLE FAMILY
Plan check applicant 18-85,8_S5,
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License gddres /
Law for the following reason (Section 7031.5, Business and - (1
Professions Code): City 9 Tel. No.
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section D
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 D
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
4authorize repres tali ve f t is County to enter upon the
ab a-menti d prop t f r inspection purposes.
��SEE REVERSE FOR EXPLANATORY LANGUAGE
L �
gri re Permittee Date