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Home My Public Portal About9150 EMPEROR AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Com ensation Insurance, CE 817 (REV. 10/81) wopti ed r af.(Sec. 3800, b. C.) 1t�_ � �� e+ COUNTY OF LOS ANGELES BUILDING AND SAFETY lcy No Campan Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING l Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET Date Applicant NEAREST CROSS ST.TUB CERTIFICATE OF EXEMPTION FROM WORKERS' BATH ,�C� COMPENSATION INSURANCE OWNER � (This section need not be completed if the work involved by r SHOWER 0-0 U, B r ,P, ,eS the permit is for one hundred dollars ($100)or less.) LAVATORY r ,z MAIL U ADDRESS O�/h G��a"Ol� ✓ I certify that in the performance of the work for which this 11 permit is issued, I shall not employ any person in any manner SINKCITY e�� / TEL. NO��, so as to become subject to the Workers Compensation Laws. DISHWASHER CONTRACTOR&Cr S 61,0/00 Date Applicant CLOTHES WASHER 0 �� NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR / Compensation provisions of the Labor Code, you must forth- CITY LAWN SPRINKLER SYSTEM , �• TEL. NO� 7( �'� with comply with such provisions or this permit shall be STATE /��7 �_ LIC CLASS deemed revoked. WATER HEATER LICENSE NO 3J / LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �� gyg (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL p DATE Pry VALIDATION d License Numb— Li,. Class t FINAL 0 Contract/ DateEJ �A I am exempt under Sec. � B.&P.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address .j r O Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the ,5 2 0 E structure is not intended or offered for sale (Section ® (? C 2 0—8 3 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 , above information is correct. I agree to comply with all County P, ordinances and State laws regulating Plumbing, and hereby (f authorize representatives of this County to enter upon the above-mentione 'etty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ,0 Sl lure of ermittee Date q� 76A667 17 5-49® APPLICATION FOR PERMIT DEPARTMENT OF BUILDING AND SAFETY COUNTY OF LOS ANGELES WILLIAM J FOX, CHIEF ENGINEER ` FOR APPLICANT TO FILL IN DISTRICT N GROUP ZONE PERMIT NO � /6� PLUMBER M. C. NOT"I�p+17�(`N` RAM CO' RECEIVED BY READY FOR DATE ISSUED c3 FIRST INSPECTION .� -5-10ADDRESS 12 �yT3 `o• Ckoverly Ave. �s �Q BUILDING CITY TEMPLE ClIX,CALIF. 'ADDRESS � ® -fL COUNTY { I LICENSE NO EXPIRESNEAREST LOCALITY V ✓W �J CROSS ST PERMIT FEES l NUMBER TYPE OF FIXTURE OR ITEM FEE OWNER lJ MAIL WATER CLOSET (TOILET) @ O 50 $ ADDRESS BATH TUB @ O 50 CITY TEL NO SHOWER @ O 50 1HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND LAVATORY WASH BASIN) @ O 50 I AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING KITCHEN SINK @ O 50 I CERTIFY THAT I POSSESS THE ABOVE VALID LOS LAUNDRY TUB OR TRAY @ O 50 ANGELES COUNTY LICENSE OR I AM THE LEGAL OWNER OF THELiSIOD IAL PROPERTY DESCRI ED ABOVE. GAS SYSTEM OUTLETS @ O 50 SIGN �a s WATER HEATER @ O 50 rIZ7fA SLOPSINK @ O 50 INSPECTION RECORD FLOOR SINK @ O 50 FLOOR DRAIN @ O 50 DISHWASHER @ O 50I DRINKING FOUNTAIN @ O 50 URINAL @ O 50 ..1 HOUSE SEWER @ O 50 Q Z MISCELLANEOUS O APPROVALS DATE INSPECTOR S NAME ROUGH PLUMBING GAS PIPING GAS VENT CESSPOOL @ 1 00 CESSPOOL SEPTIC TANK I SEPTIC TANK I DRAIN ( ) PIT ( ) @ 1 00 SEWER PERMIT 1 00 GAS TEST $� I !!r—e)> UTILITY CO NOTIFIED ' TOTAL FEE ® FINAL ' D S S-17 25M BETS I1-46 APPLICATION FOR PERBIIT .DEPARTMENT-OF BUILDING AND SAFETY PLUMBING� � ' c COUNTY OF LOS ANGELES WM J. FOX.CHIEF KNGINEER NATURE OF INSTALLATION DISTRICT NO GROUPZO E PERMIT ROUGH FIXTURES 1—� SEPTIC TANK COMPLETE .5' l �� 5/� _ �RE�C�EIV�EDD BY READY FOR DA E ISSUED HEATER CE88POOL �y OII'I+ FIRST INSPECTION GAS 18CELLANEOUB /fAJJPPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY K NAME .(/lG f�tb//.�l $ � �7T1 +< .Yl ADDRESS �JOB 4f� ADDRESS U d�/ � C/ � R LOCALITY / a-0- D / NEAREST OJ. CITY TEL No �'' aD CROSSST S- C - OUNTY p� CERT No �`� `EXPIRES K NAME LOCATION OF SEPTIC TANK, OR CESSPOOL 3 MAIL DRESS NORTH O CITY TEL No 1 AM THE LEGAL POSSESSOR OF THE ABOVE LOS ANGELES COUNTY CERTIF`IIC,A�T�E' Of QUALIFICATION' PLUMBER 4j.� I AM THE LEGAL OWNER OF THE PROPERTY DESCRIBED ABOVE. N OWNER CORRECTIONS SOUTH _1 ,DESCRIPTION OF WORD z IBATH TUB FURNACE L7 Q' / SHOWER DISHWASHER O LAVATORY REFRIGERATOR , KITCHEN SINK WATER SOFTENER FLOOR SINK BAND TRAP SLOP SINK FLOOR DRAIN WASH TRAY URINAL APPROVALS f WATER CLOSET DRINKING FOUNTAIN DATE INSPECTOR'.NAME WATER HEATER DENTAL LAVATORY ROUGH PLUMBING // METER- . GAS OODA FOUNTAIN OUTL GAS PIPING / GA8 VENT CESSPOOL I TOTAL NUMBER OF FIXTUR;TAANKF �G -SEPTIC TANK CESSPOOI gEPTICSEWER v Y UTILITY CO NOTIFIED �_r TOTAL FEE FINAL "�