HomeMy Public PortalAbout9132 EMPEROR AVE_Plumbing__ WORKER'S COMPENSATIONDECLARATION 20-0026 DPW 9/89 APPLICATION FOR PLUMBING PERMIT
tJ 76A667A
I hereby--affirm that I have a certificate of consent to self insure, U a
or.,a certificate of Worker's Comp4-
0114�_
Insurance, or certified
copy thereof(Sec.3800 Lab. C.) 4 0 o
r J st COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No.� - Comp . -
❑ Cer`CiTied c5py� ereby furnished. B ( 1 0
F-1fl/ FOR APPLICANT TO FILLQN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS
department. } { /� (11 NUMBER FIXTURE ORAITEM , FEE LOCALITY
Date r '/ Applicant r4 dq&e f'l�-���1'!f/-I� WATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSSST. o
BATH TUB
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) y L OWNER
/ LAVATORY
1 certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so asMAIL
SINK ADDRESS
become subject to the Workers' Compensation Laws.
10
DISWASHER CIT TEL.NO.
Date Applicant ' CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR x�
Exemption,you should become subject to the Workers' Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such / ADDRESS A,,LL4 d
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY Q u� TEL.NO. q
I hereby affirm that I am licensed under•,provisions of Chapter 9 WATER HEATER �-
(commencing with Section 7, 00) of Division 3 of the Business and STATE LIC.
Professions Code, and my license is in full force and effect.
GAS SYSTEM OUTLETS LICENSE NO. CLASS 8 V
OUTLETS OVER DISTRICT NO. PROCESSED BY cc
s' 5 PERS STEM
License Number Class
T .+
DATE _Z VALIDATION LU
:3 ff y L/ _.
Contractor kf Jk ki# I l�1S Date 1• ¢ � C0
�, FINAL f�f_`-_`9 .a Z
I am exempt under Seo °"' x BY _
BAP.C.for this reason
Date Plan check fee `'
Signatures{{ >l/ Q l PLUMBING PERMIT ISSUING FEEO$ ;'•_ti"AL -E310 90
F TOTAL FEE E EC'
Bi
Plan check applicant r' !Alfk GEE
SINGLE FAMILY `
HOME OWNER-BUILDER DECLARATION Name 0
- 1 hereby affirm that I am exempt from the Contractor's License Law o
for the following reason (Section 7031.5, Business and Professions Address
Code): .:_ i.•i:: :-t
El 1,
° Tel.No. } i
I, as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). ,
CONSTRUCTION LENDING AGENCY o
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.) /I /
Lender's Name NA Al ��dnf q�`A' 11
Lender's Address 9- a^ 2- �a/rfn A)4-k)d & &
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 o
property for inspection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
• u
D a 5-,b asM BETS '-, � ` APPLICATION FOR PERWr -
��F"SPI fE* OF BUILDING AND SAFETY LlJ � �
COUNTY OF LOS ANGELES
Wm J. FOX, CHIEF ENGINEER
NATURE OF INSTALLATION DISTRICT . GROUP ZONE PERMIT O.
ROUGH FIXTURES � III COMPLETE
4l
HEATER CESSPOOL I SEPTIC TANK RECEIVED BY READY FOR' DATB ISSUED
r FIRST INSPECTION
A9 MISCELLANEOUS
APPLICANT F,.IIL/L IN HEAVILY OUTLINED/ PJO/RATION ONLY
JOB
d' NAME // !.O<�(Jd6, ll.s1 `C =D'. ADDR686
ADDRESS �?�LX5" LOCALITY '
O �J NEAREST 0
'� CITY 4� TEL No ,2 —e yy 7/1/_ CROSS ST.
6
COUNTY
CERT NO EXPIRES KM NAME s'a��✓ :i�'�?=?) �- r �'J' J
LOCATION OF SEPTIC TANK, OR CESSPOOL z MAIL
3 ADDRESS
NORTH O
CITY TEL.No.
IAM THE LEGAL POSSESSOR OF THE ABOVE LOS
ANGELES,COUNTY CERTIFICATE OF QUALIFICATION.
PLUMBER
I AM THE LEGAL OWNER OR THE PROPERTY DCRIBED
ABOVE.
3 OWNER
CORRECTIONS
SOUTH J
DESCRIPTION OF WORK i
BATH TUB FURNACE 0
—SHOWER DISHWASHER 0
�� LAVATORY -REFRIGERATOR
KITCHEN SINK WATER SOFTENER
FLOOR SINK SAND TRAP
SLOP SINK FLOOR DRAIN
7
WASH TRAY URINAL APPROVALS
WATER CLOSET DRINKING FOUNTAIN DATE INBPBCTOR'8 NAME
/ f
WATER HEATER DENTAL LAVATORY ROUGH PLUMBING I
METER.�g _GAS --SODA FOUNTAIN
OUTL 6A9 PIPING 1+
GAS VENT I 1
CESSPOOL i
TOTAL NUMBER OF FIXTURES SEPTIC TANK
r ICESSPOOL_—SSEPTIC TANK SEWER
$ UTILITY CO NOTIFIRD
TOTAL FEE �'�
FINAL
4
D.a.s.-17 25M SETS „ asp APPLICATION FOR PERMIT
DEPARTMENT OF BUILDING AND SAFETY PLUMBING
OF LOS ANGELES
WM. J. FOX. CHIEF ENGINEER
NATURE OF INSTALLATION DISTRICT NO. GROUP O E PERMIT NO.
ROUGH FIXTURES COMPLETE �I
HEATER CESSPOOL H SEPTIC TANK R EIVED 9 READY FOR 6AIR 18 ED '
FIRST INSPECTION
GAS MISCELLANEOUS - _g �J
APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY
JOB
C NAME ADDRESS
W
m ADDRESS LOCALITY
NEAREST
J
0. CITY TEL.No. CROSS ST.
COUNTY
CERT.No. EXPIRES C NAME
LOCATION OF SEPTIC TANK, OR CESSPOOL z MAIL
ADDRESS
NORTH O
CITY TEL.No.
I AM THE LEGAL POSSESSOR OF THE ABOVE LOS
ANGELES COUNTY CERTIFICATE OF QUALIFICATION.
PLUMBER
1 AM THE LEGAL OWNER OF THE PROPERTY DESCRIBED
ABOVE.
R
3 1 OWNER
CORRECTIONS
SOUTH
J
DESCRIPTION OF WORK Z
BATH TUB FURNACE
SHOWER DISHWASHER ❑
LAVATORY REFRIGERATOR
KITCHEN SINK WATER SOFTENER
FLOOR SINK SANDTRAP
SLOP SINK FLOOR DRAIN
WASH TRAY URINAL APPROVALS
WATER CLOSET DRINKING FOUNTAIN DATE INSPECTOR'S NAME
WATER HEATER DENTAL LAVATORY ROUGH PLUMBING
METER GAS SODA FOUNTAIN GAS PIPING
OUTL
GAS VENT I I
CEG£POOL ( ��
TOTAL NUMBER OF FIXTURES SEPTIC TANK
CESSPOOI �SEPTICTANK SEWER
s
ILITY CO.NOTIFIED
TOTAL FEE
FINAL