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HomeMy Public PortalAbout9117 EMPEROR AVE_Plumbing__ �IBA667A CE GE 817(REV.8•/78) ©s 41 APPLICATION FO PL UIVCBLNG PES M1 L t , COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDINGD '� � �y� NUMBER FIXTURE OR ITEM @ FEE ADDRESS �C n� ��!'��/ WATER CLOSET LOCALITY /►� t) AC)1C—k NEAREST BATH TUB CROSS ST. ^y l C 6 e 0 0 1�LAJS✓� T tC) SHOWER OWNERJ. Li N LAVATORYMAIL 4-7 ���Plb- ADDRESS ++��ss��1y lC 5� SINK c-0 CITY& �i, TEL.NO. DISHWASHER CONTRACTOR )GI TIC_ 1r,)S'-j--adC6-RS CLOTHES WASHER ADDRESS oO ,2c G' Gtiv SWIMMING POOL RECEPTOR ,/� { � CITY ' .'yI � VGt E�j TEL.NO. ��•2 7�(� LAWN SPRINKLER SYSTEM STATE LIC. WATER HEATER LICENSE NO. �J zlr 0 CLASS GAS SYSTEM OUTLETS QC APPROVALS DATE INSPECTOR'S SIGNATURE r OUTLETS OVER UNDER SLAB WORK S PER SYSTEM ROUGH PLUMBING (0 GAS PIPING O GAS VENT u HOT WATER HEATER (0 PLUMBING FIXTURES fa GAS TEST 6 v. Neil Platt Check fee °UTILITY CO.NOTIFIED L� PLUMBING PERMIT ISSUING FEE$ I o 0 TOTAL FEE FINAL f PLAN CHECK VALIDA ON Plan check applicant Name Address City Tel. No. I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUIINAN AND STATE LAWS REGULATING P ING, PERMIT VALIDATION �U•� .1 �ICi..__ I HEREBY CERTIF THA AM ROPERLY REGISTERE A /ORREQUIRED BY LOS AN ELES O NTY ND 5 E OF AL RN OR 0 1 7 Q LEGAL OWNER OF,A D INT D O R IDE N E BOVE ES RIBE PROPERTY. C SIGNATURE OF PERMITTEE C^ DISTRIC�AO. P OCESSED (� 6- d X I ( INDUSTRIAL WASTE APPROVAL WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9/89 (� ILI I herB 'oy affirm that I have a certificate of consent to self insure, 76A667A APPLICATION FOR PLUMBING PERMIT or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No. Company F1 Certified copy is hereby furnished. BUILDING LJ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant Y WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' yBATH TUB D D CROSS ST. 67A64— .4✓E COMPENSATION INSURANCE ASSESSOR SHOWER MAP BOOK PAGE PARCEL (This section need not be completed if the work involved by the D permit is for one hundred dollars($100)or less.) /LAVATORY 6 OWNER 1 certify that in the performance of the work for which this permit �r is issued, I shall not employ any person in any manner so as toMAIL SINK ADDRESS /� iE become subject to the Workers'Compensation Laws. DISWASHER CITY 4V Q X77 f TEL.NO. Date Applicant CLOTHES WASHER -�v NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR . Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM - LICENSED CONTRACTORS DECLARATION CITY PQ �- I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencingwith Section 7000 of Division 3 of the Business and STATE ) GAS SYSTEM OUTLETS LICENSE N CLASS V Professions Code, and my license is in full force and effect. 11r OUTLETS OVER DISTRICT NO. PROCESSED BY 5 PER SYSTEM �� p License Number Lic.Class FINAL 9 J DATE oc L� VALIDATION Contractor Date (� ❑ NAL I am exempt under Sec. FBY INAL B.&P.C.for this reason Plan check fee ► Signature Date: PLUMBING PERMIT ISSUING FEE$ /6 Q Q ❑ TOTAL FEE . 0 _ �t Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name 4+i t ,; I hereby affirm that I am exempt from the Contractor's License Law 3,01 °"= •='-' for the following reason (Section 7031.5, Business and Professions Address i Code): 101 City Tel. No. t— ....r - _ o I, as owner of the property,will do the work and the structure ;�I r{L =p� _ =� is not intended or offered for sale (Section 7044, Business and Professions Code). , {- f-'-j• '`�°-I CONSTRUCTION LENDING AGENCY CHANGE 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 'f3'.�`' [ AM V1-)° 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-mentioned property for inspection purposes. Z SEE REVERSE FOR EXPLANATORY LANGUAGE � s