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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRD NG
ESS 10 15,
J/ LA r
JOHN A. LAMBIE. COUNTY ENGINEER
WILLIAM A. JENSEN,,SUP'T OF BUILDING LOCALITYNEAREST gZC
FOR APPLICANT TO FILL IN CROSS ST. 1/1 / A-I/ .
NUMBER FIXTURE OR ITEM EACH FEE ..� ^�` p
OWNER J` m�At
/f{�.. }�-/ C J
WATER CLOSET $1.25 qq
BATH TUB 1.25 ADDRESS19 G O
SHOWER 1.25 CITY TEL. NO.Z� =8Slo
LAVATORY 1.25 CONTRACTOR
SINS 1.25 ADDRESS
DISHWASHER 1.25 CITY TEL. NO.
CONTRACTOR' STATE
REGISTRATION O. COUNTY p
LAUNDRY TUB 1.25
0
CLOTHES WASHER 1.25 DISTRICT NO. GROUP Z E CESSED Y
WATER HEATER 1.50
GAS SYSTEM OUTLETS 1.50 INDUSTRIAL C
WASTE APPROVAL
OUTLETS OVER 5 PER SYSTEM .30 Q
INSPECTION,RE ORD 0
e As
h
Z
APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT $ 2 -00 UNDER SLAB WORK 1 j�
ROUGH PLUMBING v I
o TOTAL FEE Q'U GAS PIPING
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT Y P
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYEJJ 'Ft �f /;J✓
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER .®�f
PLUMBING.
I HEREBY 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 I AM THE LEGAL OWNER OF,AND INTEND TO
RESIDE IN,THE ABOVE DESCRIBED RESIDENTIAL ROPERTY. UTILITY CO. NOTIFIED —
SIGNATURE // I
OF PERMITTEE FINAL /3®B{a.A-
VALIDATIQ' ROBERT A. WOOD Y
CK. M.O. CASH SUPERVISING MECHANICAL ENG'R
L229612 JUN 4 5 D 5.00N
"flea qs7 1/ s-so i® APPLICATION FOR PERMIT
DEPARTMENT'OF BUILDING AND SAFETY
COUNTY OF LOS ANGELES PLUMBING 1
WILLIAM J. FOX, CHIEF ENGINEER
DISTRICT NO. GROUP I ZONE PERMI NO.
FOR APPLICANT TO FILL'IN 3-71 �
PLUMB] ���,Q(>,I�'[� C RECEIVED BY READY FOR DATE ISSUED
Y VVI\ FIRST INSPECTION
ADDRE044 {>�J_ Campy - Mant"PrPv Park, L. Tr
CU
t �rt BUILDING '1
CITY ATIantic 2.4654 - T �eriand 3'1010) ADDRESSCOUNTY
�/ i•t�` ` ��e4"21`:f[.A-a
L CENSE NO. /..'L !^E �""✓ EXPIRES � '�' LOCALITY „g ifI }"- i.t" h
6 J !
PERMIT FEES o / CRROSSSTfi.t� <'=' r,_,
- .C .
r r�k7. �
NUMBER TYPE OF FIXTURE OR ITEM FEE OWNER .t"�.2
PMAIL
1
p I WATER CLOSET (TOILET) @ 0.50 $ I SIC ADDRESS
'r BATH TUB @ O.50 I -m OITY TEL. NO.
_J SHOWER @ 0.50 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS
/ LAVATORY (WASH BASIN) @ 0.50 APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND
AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND
/ I KITCHEN SINK @ 0.5011 c-e-i, STATE LAWS REGULATING PLUMBING.
' 1 CERTIFY THAT 1 POSSESS THE ABOVE VALID LOS
LAUNDRY TUB OR TRAY @ 0.501 ` !, ANGELES COUNTY LICENSE, OR 1 AM THE LEGAL OWNER
OF THE RESIDENTIAL PROPERTY DESCRIBED ABOVE.
GAS SYSTEM OUTLETS @ 0.101 �• SIGNATURE OF `- �/�-t;.r /'
WATER HEATER @ 0.50 I ,� �'' PERMITTEE r D
I SLOP SINK @ 0.50 I INSPECTION RECORD
FLOOR SINK @ 0.50
FLOOR DRAIN @ 0.501
DISHWASHER @ 0.501
i
DRINKING FOUNTAIN @ 0.50 �� ••�k
IURINAL @ 0.501 I -J
1 HOUSE SEWER @ 0.501 1 Q
Z
1 MISCE LLANEOUS ,
0
I�
I�
I
I
APPROVALS
DATE INSPECTOR'S NAME
ROUGH PLUMBING 9�i(.,'!'% L.? c••.•-!..,�+,�7i �'T�
' GAS PIPING
rGAS VENT _
CESSPOOL @ 1.00 I CESSPOOL 1
SEPTIC TANK: I SEPTIC TANK
I DRAIN ( ) PIT ( ) @ 1.001 I SEWER 1
PERMIT . I 1.00 GAS TEST
TOTAL FEE $
UTILITY CO. NOTIFIED
,�� �'� "'" d
I• �' a FINAL C,� $
WORKERS' COMPENSATION DECLARATION Aq PPUCAVON FOP PLUM p NG PEROT
I hereby affirm that I have d•ceitificote of consent to self 20.0026 DPW 6/87 C
insure, or a certificate of Workers' pensation Insurance, 76A667A lul
or a certified cc/opythrtheer�rreoll (Sec. 3 Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy Nal-� �Compa
Certified copy is hereby furnisVed.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING G /'� U -�
Certified copy is filed with the county building inspec- ADDRESS / � V
tion depar ment' NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Q 01 WATER CLOSET
Date V Appli4ant NEAREST
CERTIFICATE OF EXEMPTION FROM WO RS' BATH TUB CROSS ST.
COMPENSATION INSURANCE, SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work'for which this 'TT
permit is issued, I shall not employ any person in any manner SINK CIT r / TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR �-
Date Applicant CLOTHES WASHER ADDRESS` J61
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL. NO. a
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC. /7
deemed revoked. WATER HEATER LICENSE NO. .2 �] S CLASS< �ZQ
LICENSED CONTRACTORS DECLARATION RI PROCESSED PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS oo
(commencing with Section 7000) of Division 3 of the Business OUTLETS'OVER a ���JJJ (�ll1JJJ
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM . FINAL VALIDATION phi
License Nu er
Lic. Class -aG DATE U.
FINAL��
Contractor Date Z BY 0
❑ O,
I exempt under ec. � _�7�„ftj � W
B.&P.C. for this reason )
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check pplicant
SINGLE FAMILY 5
HOME OWNER-BUILDER DECLARATION Name 4� FiLCTo4
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and 3 Q
Professions Code): City Tel. No. I� "'
❑ 1, as owner of the property, will do the work and the 1 T
structure is not intended or offered for sale (Section D TOTAL ,�?o �
7044, Business and Professions Code). -_
CONSTRUCTION LENDING AGENCY CECK 16050
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued Me ow
(Sec. 3097, Civ. C.).
Lender's Name : -{ � G/Jbl�7
Lender's Address 5 I N 400
1 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
outhori representatives of this County to enter upon the
obov m alio d operty for inspection p rposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
SigIgure of Permitte Date