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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS-ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �/
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS oG.
WILLIAM A. JENSEN, SUPT OF BUILDING ypCALI'[Y
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM OWNER _
WATER CLOSET my
/ BATH TUB ADDRESS
CITY TEL NO.
SHOWER
CONTRACTO
LAVATORY
ADDRESS
SINS
DISHWASHER .. CITY TEL NO _ �—
LAUNDRY TUB REGISTRATION NO. �9��� COUP
CLOTHES WASHER DISTRICT NO. GROUP ZONE B ESSED BY
WATER HEATER LY � / ��
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL }
INSPECTION RECORD / O
/h�/S/Gz ��Et - . y
�r n.
® $1.00 PER ITEM
OR FIX'fUAE $ /h DO APPROVALS PATE, INSPECTOR'S 61GNaJURE
v PERMIT $ Y177 00 UNDER SLAB WORK I Oh Mp.
TOTAL FEE ROUGH PLUMBING O
GAS PIPING �' F
1 HEREBY ACKNOWLEDGE THAT 1 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.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES 0-I(-CIL �.�..�_..X,
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
- CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE GAS TELT
DESCRIBED RESIDENTIAL PROPEIjTY. UTILITY CO. NOTIFIED V i
SIGNATURE 1
OF PERMITTE O
. . .....:. .. .....:-: _ . FINAL �Z�/.•Gal
7ALIDATION ROBERT A. WOOD V
cK. M.D. CASH SUPERVISING MECHANICAL ENG'R
lCo5 7 0 4-� OCT18 5 D 1 5.00~ Q
. ,WORKER ';COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �
••I hereby affirm that I have a certificate of consent to self 76A667A
insure, ar a certificate of Workers' Compensation Insurance, CE 817(REV. 10/8I)
or a certified copy therepf,jsec. 3800, Lab. .) /q COUNTY OF LOS ANGELES �' BUILDING AND SAFETY
Policy No.CCOO (R �C'/ompany rU/
Certified copy is hereby furnished.
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 121 ll I
Certified copy is filed with the county building inspec- ADDRESS �1 1 Q Q��h
tion Oportment. NUMBER FIXTURE OR ITEM C7E FEE LOCALITY -
WATER CLOSET t-le �� t
Date �� Applica NEAREST �L
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. .pq/
COMPENSATION INSURANCE SHOWER OWNER �A�h c�
(This section need not be completed if the work involved by A
nn nthe permit is for one hundred dollars ($100)or less.) LAVATORY MAIL
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(/(/(% GJf(C
so as to become subject to the Workers Compensation Laws. DISHWASHER _ u0 c,tJ
/n CONTRACTOR Ov91,00m -SOl .
Date —/"' Applicant - CLOTHES WASHER ADDRESS -P
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR 1� h
-13 ill
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY fQ h(7 J _ TEL NO.
with comply with such provisions or This permit shall be STATE r, IL_/,IQ
7/ ^� / ^� LIC.
deemed revoked. WATER HEATER LICENSE NO. L_ ^ / 6, / CLASS C� 7
n. LICENSED CONTRACTORS DECLARATION DISTRICT NO, ROCESKID By
I hereby affirm that GAS SYSTEM OUTLETS am licensed under provisions of Chapter 9 S' 0 f✓
(commencing with Section y tic of Division 3 of the Business OUTLETS OVER 0 }
and Professions Co% de,and my license is in full force
,^Land
//effect. 5 PER SYSTEM FINAL VALIDATION IY
License Number CJS �9�7 Lic. Classes �O p�Q DATE / V
/� 71�kFIN F
Contractoi?O�UW'{Se Date 7�/� BY �� ,�� 0
V
❑ W
I am exempt under Sec. IY
N
B.BP.C. for this reason D Z
Plan check fee
Dote:
PLUMBING PERMIT ISSUING FEE S �Q
S'gnnt rr u�' ��7L'y,/`�^
— _ TOTAL FEE
Plan check applicant 27 3 9 A
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name . o e o o e 5
1 hereby affirm that I am exempt from the Contractor's License Address ? o ^ 3 0 5 0
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. e o - 30 ,505
❑ I, as owner of the property, will do the work and The
structure is not intended or offered for sole (Section 0 7 V6—8 4
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, Ci, 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
abov - to Bonedproperty for inspection purpos S.
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of Permittee Date